 In this issue ...
Before sending bills to collections, check again for OHP eligibility
Always verify the patient’s Oregon Health Plan (OHP) eligibility for the date of service you are trying to bill. Even if you have checked before, check again.
- Some members can have their OHP eligibility backdated up to 90 days before their original approval date for OHP.
- OHP eligibility can be updated or corrected at any time.
If the member is eligible, then the next step is to bill the Oregon Health Authority (OHA) or the member’s coordinated care organization (CCO). OHA accepts claims up to one year after the original service date.
Changes to Oregon Health Plan billing rule, effective January 1, 2018
The Oregon Health Authority (OHA) made several changes to Oregon Administrative Rule 410-120-1280 – Billing in the General Rules program.
Many changes were to support identifying and billing all other resources first, including Medicare, private insurance, and those liable for personal injury claims, before billing the division for fee-for-service Medicaid services.
Changes in Section 8 of this OAR (“Third Party Liability”) include:
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Part (b): Adds that providers should ask patients at the point of service or prior to billing if they have other health insurance. If providers learn of other resources that were not in the state’s eligibility verification system, providers must report the new resources at www.ReportTPL.org.
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Part (c): Adds that TPL can include Personal Insurance Protection or Workers Compensation if the claim is related to a personal injury; and explains billing options in cases of personal injury claims.
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Part (g): Providers cannot return payments made by the division in order to bill other resources discovered after the fact.
To ensure appropriate billing:
- Please review this rule and follow the updated guidance.
- Share this information with your billing departments or vendors.
- Verify eligibility before providing service or billing Medicaid.
- Ask the patient about their health care coverage, and report new coverage to www.ReportTPL.org.
Additional services available through the Reproductive Health Equity Act (RHEA) effective April 1, 2018
Starting April 1, 2018, women enrolled in CAWEM Plus (CWX) will be able to access the following care for 60 days postpartum:
- Comprehensive medical services, and
- Immediate postpartum reproductive health care, including immediate postpartum IUDs, implants and female sterilization.
In addition, individuals enrolled in CAWEM (CWM) will be able to access the following services starting April 1:
- Female sterilization, and
- Hospital-based abortion services.
Providers should bill OHA fee-for-service for these services. For sterilizations, please continue to obtain sterilization consent at least 30 days prior to the procedure (as outlined in Oregon Administrative Rule 410-130-0580 - Hysterectomies and Sterilization).
In addition, RHEA covers the following reproductive health services for any individual who would otherwise be eligible for medical assistance if not for their immigration status:
- Contraception and contraceptive-related services, including counseling;
- Well-woman visits;
- Screenings for breast and cervical cancer;
- Screenings for pregnancy and sexually transmitted infections (STIs);
- Counseling on STIs, relationship safety, and tobacco use;
- Mammography and screening for genetic cancer risk factors; and
- Outpatient abortion services (effective January 1, 2018).
Where can individuals receive care?
Individuals can access these services at any clinic within the Reproductive Health Program network. This network includes many local county health departments, Planned Parenthood clinics, federally qualified health centers (FQHCs), and other community-based health centers. Individuals may complete a Reproductive Health Program Enrollment Form onsite and receive services and supplies the same day. For a complete list of Reproductive Health Program clinics, please visit: www.healthoregon.org/rhclinics.
Webinar: How to submit FFS physical health prior authorization requests to OHA
Learn how to get your prior authorization requests reviewed faster! This webinar will feature a training video, followed by live Q&A with clinical review professionals from the Health Systems Division.
Who should attend?
Anyone who submits FFS prior authorization requests to OHA for:
- Medical/surgical services
- Durable medical equipment and supplies
- Imaging and laboratory tests
- Physical or occupational therapy
- Hearing aids
- Communication Assistive Devices
- Speech therapy
- Out-of-hospital births
Please share this information with others who submit physical health prior authorization requests to OHA. More information, including slides and a training flyer, are on the new OHP prior authorization page.
Billing for gender-specific services
To process claims for gender-specific services provided cross-gender, OHA now follows Medicare guidelines for coding claims to bypass gender-specific edits. When billing for these services, please identify them as follows:
- Add the KX modifier on professional claims.
- Add condition code 45 on hospital claims.
Diagnosis codes on anesthesiology claims
When billing for anesthesiology services, please be sure the primary diagnosis code on the anesthesiology claim is the same as the primary diagnosis code on the claim for the primary service (for example, surgery).
- As ancillary codes, anesthesia codes are only covered when the primary service is covered.
- Using the same primary diagnosis code on both the primary and ancillary claim helps ensure that the ancillary claim processes the same as the primary claim.
Avoid claim denials by reporting your current EDI submitter to OHA
Whenever you change electronic data interchange (EDI) submitters, you need to report the change by completing and mailing a new Trading Partner Agreement (OHA 2080) to OHA. Otherwise, claims will be denied due to provider/submitter mismatch.
If you see these errors for submitted claims, report your current EDI submitter to OHA on a new Trading Partner Agreement form as soon as possible:
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On paper remittance advices: Explanation of Benefit code 9013 – Provider and submitter mismatched
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On electronic remittance advices and the Provider Web Portal: Adjustment Reason Code 223 and Remark Code N407 – You are not an approved submitter for this transmission format.
Required fields on the Trading Partner Agreement are outlined in red. These fields must be completed in order for OHA to accept and process your new agreement.
Billing for services to Medicare members
If you serve Medicare members, please note the following:
- Medicare Savings Programs (SMB and SMF) are not OHP benefit plans. They only pay Medicare premiums. Providers are allowed to bill SMB and SMF members for Medicare cost-sharing.
- OHP benefit plans for Medicare members are MED and BMM. Providers may not bill members for Medicare cost-sharing or services covered by OHP or Medicare. To learn more about billing responsibilities for Qualified Medicare Beneficiaries, read our fact sheet.
Where to send paper claims
The Oregon Health Authority (OHA) accepts only the following types of claims at its 500 Summer Street address:
- Hysterectomy and sterilization claims
- Transplant claims
- Out-of-state claims
- Claims over one year old
- Requests to reconsider CAWEM claims, pharmacy claims, non-covered service determinations, and incorrect denials due to administrative error
If you send any other types of claims to 500 Summer Street, OHA will mail them to the DHS|OHA processing center, which delays processing.
For faster processing:
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- Claim-specific questions and issues – Contact Provider Services at 800-336-6016 (option 5).
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EDI and the 835 ERA – Contact EDI Support Services or visit the EDI page.
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Provider enrollment updates - Contact Provider Enrollment at 800-336-6016 (option 6).
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Pharmacy and prescriber questions (for technical help and fee-for-service prescription PAs) – Contact the Oregon Pharmacy Call Center at 888-202-2126. You can also fax PA requests to 888-346-0178.
- Prior authorization status – Call the PA Line at 800-336-6016 (option 3).
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Web portal help and resets – Contact Provider Services at 800-336-6016 (option 5).
Find more phone numbers, email addresses and other resources in OHA's Provider Contacts List.
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