 In this issue ...
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.
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.
Questions?
About prescriber enrollment: Contact Provider Enrollment at 800-336-6016 (Option 6) or provider.enrollment@dhsoha.state.or.us.
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.
No updates at this time.
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.
Recent rule revisions
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410-121-0030 - Amending Preferred Drug List September 27, 2018, DUR/P&T Actions
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410-123-1220 - January 1, 2019, Coverage According to the Prioritized List of Health Services
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410-123-1245 – The “Incentive” for Oral Health Prevention – Fee-for-Service Dental Incentive Program
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410-141-3070 and 410-141-3225 - CCO Prior Authorization Response Times for Provider-Administered Drugs
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410-141-3258, 410-141-3259 - New CCO Rules on Contract Termination and Closeout Requirements and Sanctions
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410-141-3060 - Medicare/Medicaid Dual Eligible Enrollment Changes
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410-172-0650 - Extends Period for Requesting Prior Authorization of Behavioral Health Services from 30 to 90 Days
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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.
- 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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