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December 2016
In this issue:
Health System Transformation
- Medicaid Electronic Health Records (EHR) Incentive Program
Other provider updates
- Help us process your CMS-1500 claims faster
- Oregon DRG hospitals - Ambulatory Payment Classification (APC) grouper delay
- Resources to help providers with common questions and concerns
- State offices closed December 26 for Christmas holiday observance
- Reminder: January 1 changes to OHP benefits and copayment requirements
- Reminder: OHA accepts only the ADA 2012 paper claim form
- Reminder: Please wait one month before billing OHP newborn claims
Medicaid Electronic Health Records (EHR) Incentive Program
Program Year 2016 attestations due March 31, 2017
- Starting January 1, 2017, both eligible professionals and eligible hospitals can submit their 2016 adopt, implement or upgrade (AIU) and meaningful use (MU) attestations.
- Eligible professionals can continue to submit their first year 2016 AIU and MU attestations.
The due date for all Program Year 2016 attestations is March 31, 2017.
Please include the following documents as part of your attestation:
- Copy of meaningful use summary report;
- Security risk assessment (SRA). HealthIT.gov offers an SRA tool to help providers complete this assessment;
- Deficiencies noted and the corrective action plan(s), including target dates for implementation; and
- Documentation of who completed the SRA.
This is the last year to begin the program (coming in under AIU or MU payment year one).
New CMS rules
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Hospital Outpatient Prospective Payment System (OPPS) Changes to Better Support Hospitals and Physicians and Improve Patient Care - Please view the CMS Final Rules for additional details.
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Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 3 and Modifications to Meaningful Use in 2015 Through 2017 - Please view the CMS Final Rules for additional details.
For more information
Help us process your CMS-1500 paper claims faster
When submitting professional claims to the Oregon Health Authority (OHA) using commercially available versions of the CMS-1500 paper claim form, please remember the following:
Enter member last names carefully
Field 1 on the form requires entering the name in Last Name, First Name, Middle Initial order.
- When the member only has one last name, such as Smith, you do not need to use a comma to separate the Last Name from the First Name.
- However, if the member has two last names, such as Smith Jones, please use a comma to separate the Last Name from the First Name.
For example, Smith Jones John L will be entered with the Last Name Smith, First Name Jones, and Middle Name John L. This will likely result in a name and ID mismatch error for the claim.
Entering Smith Jones, John L will allow us to process the claim with the correct Last Name and First Name.
Enter the Rendering Provider’s Oregon Medicaid provider number and NPI
In Box 24J of the CMS-1500, please enter the Oregon Medicaid ID and National Provider Identifier (NPI) for the rendering provider on the claim.
Do not put other identifiers, such as taxonomy codes, in this field. We need the rendering provider’s unique ID numbers assigned by NPPES and OHA.
To learn more about how to correctly submit paper CMS-1500 claims, and how to submit professional claims using the Provider Web Portal, read OHA’s Professional Billing Instructions.
Ambulatory Payment Classification (APC) grouper delay
Medicare’s outpatient APC grouper for DRG hospitals becomes effective January 1, 2017. Unfortunately, we will not be able to update our system effective January 1. When we make this update, we will let you know.
State offices closed December 26 for Christmas holiday observance
The Health Systems Division, along with most state offices, will be closed on Monday, December 26, to observe the Christmas holiday. Go to our Office Closures page to find out which contacts are available on state office closure dates..
Resources to help providers with common questions and concerns
Before calling OHA, be sure to review the following resources on the OHP website:
We hope these help you avoid some common billing issues. You can find more resources on the OHP Tools for Providers page (try our Searchable Tools list).
Reminder: January 1 changes to OHP benefits and copayment requirements
OHA is making changes to Oregon Health Plan (OHP) benefits and copayment requirements. The changes apply to services covered by OHA and all coordinated care organizations on and after January 1, 2017.
To review the changes coming January 1, please read our December 8 announcement.
Benefit changes:
The Health Evidence Review Commission (HERC) has published the pending 1/1/2017 Prioritized List of Health Services (The List). This List takes effect January 1, 2017.
Copayment requirements:
Starting January 1, copays will be removed from all OHP services. To learn more, read our proposed revisions to the OHP copayment rule (410-120-1230). The final version of the rule will be posted on the General Rules policy page.
Reminder: OHA accepts only the ADA 2012 paper claim form
As of June 1, 2014, the only dental claims OHA accepts on paper are those submitted on commercially available versions of the ADA 2012 claim form. You can find current billing instructions on the OHP billing tips page.
- Please do not submit copies or other versions of this form to OHA.
- If you are unable to submit a commercially available copy of this form, please submit claims electronically.
You can use electronic data interchange or the Provider Web Portal at https://www.or-medicaid.gov. Billing electronically for all your claims is not only faster – it results in lower denial rates and can save you time and money. Paper claims are seldom required.
To learn more about billing electronically with OHA, please visit our Electronic Business Practices page.
Reminder: Please wait one month before billing OHP newborn claims
Every month OHA recovers a small number of payments made in the preceding month for services to newborns who are now enrolled in a CCO. This is because it is the CCO’s responsibility to pay for these services.
- Once the birth is reported, we enroll children born to CCO members in the mother’s plan.
- Depending on when the birth is reported to us, this process may take up to a month to complete.
- After that, you need to bill the CCO to seek reimbursement for these services.
To avoid future recoveries for newborn services:
What you will see on the paper remittance advice (RA), electronic remittance advice (ERA) or Provider Web Portal (PWP):
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On the paper RA: Adjusted claims will have an Internal Claim Number (ICN) beginning with “52.” The “Detail EOBs” for these ICNs will list Explanation of Benefits (EOB) code EOB 0090 – Service is covered by a managed care plan. Claim must be billed to the appropriate managed care plan.
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On the ERA or PWP: The ERA should list these adjustments as overpayment recoveries. PWP will show the adjustment ICN as a denied claim. In both ERA and PWP, the reason for recovery will be Adjustment Reason Code 24 - Charges are covered under a capitation agreement/managed care plan.
To learn more about recovery of overpayments or appeals, please see Oregon Administrative Rules 410-120-1397(7), 410-120-1560 and 410-120-1580 in the General Rules guidelines.
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