Provider Matters - December 21, 2018

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Updates about claim processing, policy and resources for Oregon Health Plan providers

November 30, 2018

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In this issue ...

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Important reminders

Changes to the Prioritized List of Health Services effective 1/1/2019

The Health Evidence Review Commission (HERC) has updated the Prioritized List of Health Services and guideline notes, effective January 1, 2019. Changes include:

  • Code changes to condition/treatment pairs on numerous lines, due to new evidence on the effectiveness or ineffectiveness of treatments
  • Technical changes to prioritize new CPT/HPCPCS codes, add previously omitted condition/treatment codes, correct diagnosis/treatment pairing, and remove obsolete codes
  • 10 new guidelines, 16 revised guidelines, and 1 deleted guideline
  • New coding specifications on three lines
  • Revised statement of intent on palliative care

The Oregon Health Authority (OHA) will update its claim system to reflect these technical changes, effective January 1, 2019.

To learn more:
Visit the HERC website. A full description of the January 1 changes is available in HERC’s Notification of Interim Changes.

To be informed when HERC announces pending changes to the Prioritized List, sign up for HERC email updates.


Medicaid Electronic Health Records (EHR) Incentive Program

The Oregon Health Authority will accept Program Year 2018 attestations starting January 14, 2019 and ending March 31, 2019.

For questions or more information:
Please visit the Medicaid EHR Incentive Program website or contact the Medicaid EHR Incentive Program team at 503-945-5898 (Salem).

Changes to Oregon Health Plan (OHP) prescriber enrollment implementation: Acton required

The Oregon Health Authority (OHA) has postponed implementation of the prescriber enrollment requirement for fee-for-service Oregon Health Plan prescription claims from November 13, 2018 to March 1, 2019. 

  • Too many prescribers have not enrolled at this time, which would disrupt the care of OHP members. OHA is expanding its provider outreach strategies to get more prescribers enrolled to avoid interruptions to members’ prescription therapy.

  • To help us with this plan, please share this requirement with your colleagues and encourage prescribing providers and pharmacies to verify that OHA's system recognizes them as an Oregon Medicaid provider.
  • If they aren’t recognized as Oregon Medicaid providers, they need to enroll with OHA or their local coordinated care organization (CCO) as soon as possible.

How to enroll
To enroll with OHA:

  • Prescribing providers can enroll using the OHP 3113 form.
  • Pharmacies and other providers seeking direct reimbursement from OHA will need to complete a packet of four enrollment forms. To learn which forms to complete and submit, visit OHA's Provider Enrollment page.

To enroll with a CCO, contact the CCO.

About prescriber enrollment: Contact Provider Enrollment at 800-336-6016 (Option 6) or

About fee-for-service prescription claims: Contact the Pharmacy Call Center at 888-202-2126. This number is for providers only.

About coordinated care organization (CCO) claims: Contact the CCO.

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Training and technical assistance

No updates at this time.

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OHP coverage of National Diabetes Prevention Program lifestyle change programs effective 1/1/2019

Starting January 1, 2019, the Oregon Health Plan will cover services provided by National Diabetes Prevention Program (National DPP) lifestyle coaches to OHP members eligible for National DPP lifestyle programs.

Changes to OHP coverage of Medication-Assisted Treatment effective 1/1/2019

With the current opioid epidemic, expanding access to Medication Assisted Treatment (MAT) is a high priority for OHA and the Governor’s Office. To that end, OHA is opening several MAT codes, and corresponding implant/injection codes, for fee-for-service payment effective January 1, 2019.

You can read OHA’s fact sheet to view the new codes, rates and billing changes.

To learn more
Visit the OHA website to learn about Medication-Assisted Treatment and Recovery in Oregon and view the list of approved opioid treatment programs.

Visit the SAMHSA website to learn how physicians, NPs and PAs can qualify for a bupenorphrine waiver; and how currently waivered providers can apply to treat more than 30 patients under their current waiver.

When billing for maternity care using global codes, bill OHA or the CCO based on the mother’s enrollment status on the day of delivery

The code set for maternity care includes options for billing as one global package or billing the prenatal care, delivery, and postpartum care separately.

When billing for these services as a global package and an OHP member’s physical health enrollment changes during the pregnancy:

  • If the member is in a CCO on the day of delivery, bill all care to the CCO, even if most or all care occurred prior to the patient’s CCO enrollment.
  • If the member is FFS on the date of delivery, bill all care to OHA, even if most or all prenatal care occurred while the member was in a CCO.
  • Do not bill both the CCO and OHA.

When billing separately for prenatal, delivery and postpartum care, please continue to bill OHA or the CCO for each type of care based on the mother's enrollment status on the date of service.

Standard guidelines for when to use global billing still apply (refer to the current CPT Handbook).

DRG hospitals: Version 36 Medicare Severity-Diagnosis Related Group (MS-DRG) grouper delayed

The Version 36 MS-DRG grouper became effective Oct. 1, 2018. Unfortunately, we do not have an estimate of when we will be able to update our system with the new grouper. When we make this update, we will let you know.

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Rules and program changes


Recent rule revisions

  • 410-121-0030 - Amending Preferred Drug List September 27, 2018, DUR/P&T Actions
  • 410-123-1220 - January 1, 2019, Coverage According to the Prioritized List of Health Services
  • 410-123-1245 – The “Incentive” for Oral Health Prevention – Fee-for-Service Dental Incentive Program
  • 410-141-3070 and 410-141-3225 - CCO Prior Authorization Response Times for Provider-Administered Drugs
  • 410-141-3258, 410-141-3259 - New CCO Rules on Contract Termination and Closeout Requirements and Sanctions
  • 410-141-3060 - Medicare/Medicaid Dual Eligible Enrollment Changes
  • 410-172-0650 - Extends Period for Requesting Prior Authorization of Behavioral Health Services from 30 to 90 Days
  • 410-172-0705 - Phased Early Adoption of Standardized Rates for Licensed Mental Health Residential Treatment Homes and Facilities

Sign up to get rule updates via text or email

You can also sign up to get text or email updates about:

To learn more, read about how to sign up for rulemaking notices.

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Need help?

  • Claim-specific questions and issuesContact Provider Services at 800-336-6016 (Option 5).
  • EDI and the 835 ERAContact EDI Support Services or visit the EDI page.
  • Provider enrollment updates - Contact Provider Enrollment at 800-336-6016 (Option 6).
  • 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).
  • Web portal help and resetsContact Provider Services at 800-336-6016 (Option 5). 

Find more phone numbers, email addresses and other resources in OHA's Provider Contacts List.