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January 2017
In this issue:
Health System Transformation
- New provider collaboratives coming soon
- Medicaid Electronic Health Records (EHR) Incentive Program
Other provider updates
- OHA now denies claims for Provider/Submitter mismatch
- Electronic Document Management System (EDMS) upgrade coming February 1, 2017
- Institutional providers – Please enroll your attending physicians with Oregon Medicaid
- Provider Web Portal tip for quicker claim searches
- Webinars – Disability and Geriatric Competent Care to Medicare-Medicaid Enrollees
- Reminder: Please wait one month before billing OHP newborn claims
New provider collaboratives coming soon
The Oregon Health Authority (OHA) is pleased to continue its series of provider collaborative webinars in 2017. Sign up today for these topics:
Code groups for claim processing and prior authorization
Learn how to use the diagnosis code and procedure code groups available on the Oregon Health Plan (OHP) website; then learn how to correctly submit fee-for-service prior authorization requests to OHA.
Migrant Clinicians Network’s (MCN) “Health Network” system and Provider Summit Q&A
Learn how to refer patients for this free service, how the program works and its benefits for migrant health care.
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).
For more information
OHA now denies claims for Provider/Submitter mismatch
OHA now denies claims from EDI submitters who are not listed on your current Trading Partner Agreement with OHA.
- The paper remittance advice will list the denial reason using Explanation of Benefit code 9013 (Provider and submitter mismatched).
- 835s and the Provider Web Portal will list the denial reason using Adjustment Reason Code 223 and Remark Code N407 (You are not an approved submitter for this transmission format).
To avoid these denials, report your current EDI submitter to OHA by completing and mailing the new 2-page Trading Partner Agreement (OHA 2080, revised 8/16) to EDI Support Services. If you fill out the current TPA form electronically, the PDF will let you know when you have missed a required field.
To learn more about how to complete this form, read our line-by-line instructions and other resources on our EDI page.
If you have any questions, please email us at DHS.EDISupport@state.or.us.
Electronic Document Management System (EDMS) upgrade coming February 1, 2017
On February 1, 2017, DHS/OHA will upgrade the EDMS software used to process the following documents that you send to OHA:
- Paper claims mailed to OHP PO Boxes
- Requests and correspondence faxed to central OHP fax numbers using the MSC 3970 (EDMS Coversheet)
We expect no service interruptions as a result of this change. The only change you should see is improved processing time due to:
- Automatic recognition of CMS-1500 and UB-04 claim forms
- Improved document capture
The upgrade does not change how you need to submit documents to OHA. To learn more about submitting documents to EDMS, read our tips about the EDMS Coversheet.
Institutional providers – please enroll your attending physicians with Oregon Medicaid
As of October 1, 2015, OHA requires the attending physician’s National Provider Identifier (NPI) on all fee-for-service institutional claims submitted to OHA.
- The NPI must be registered with the National Plan and Provider Enumeration System (NPPES).
- Later this year, these claims will also require the attending physician’s Oregon Medicaid ID. This means that once this change takes place, OHA will deny claims that do not include the attending physician’s Oregon Medicaid ID.
To prepare for this change, please enroll your attending providers with OHA at your earliest convenience.
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Providers who plan to bill OHA directly must complete a full enrollment packet that includes the OHA 3972, 3974, 3975 and attachment specific to their provider type, as listed on the OHP Provider Enrollment page.
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Providers whose services are billed by a clinic, organization or other entity may be enrolled using only the OHP 3113 form.
To learn more about Oregon Medicaid provider enrollment requirements, visit the OHP Provider Enrollment page.
To see if your attending providers are already enrolled with OHA, use our Oregon Medicaid provider verification tool on the Provider Web Portal. Just enter the provider’s NPI and click “Search.”
Questions?
If you have questions about enrolling with OHA, call Provider Enrollment at 800-422-5047.
Provider Web Portal tip for quicker claim searches
When searching for a claim in the Provider Web Portal at https://www.or-medicaid.gov, please include, at a minimum, the following information:
- Date range for the claims you are looking for
- The patient’s eight-digit ID number (as shown on the Oregon Health ID)
Searches that do not contain this information not only run long, but cause system slowness for other Provider Web Portal users.
To learn more about how to use the Provider Web Portal, please visit the OHP Provider Web Portal page.
Webinars – Disability and Geriatric Competent Care to Medicare-Medicaid Enrollees
The federal Medicare-Medicaid Coordination Office is offering the following webinars to health plans and other provider organizations to improve the quality and delivery of care for dually eligible individuals.
These webinars provide resources for health plan and PACE organization staff, including directors of medical care, care management/care coordination, and/or long-term services and supports staff.
Geriatric Competent Care: Applying Promising Practices to Advance Care of Medicare-Medicaid Enrollees with Dementia
Introduction to the 2017 Disability-Competent Care Webinar Series
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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