Provider Matters - January 25, 2019

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

January 25, 2019

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In this issue ...

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Important reminders

Reminder from CMS – Qualified Medicare Beneficiary billing requirements

Medicare providers may not bill Qualified Medicare Beneficiaries (QMB) for Medicare deductibles, coinsurance, or copays, but state Medicaid programs may pay for those costs. Providers who inappropriately bill individuals enrolled in QMB are subject to sanctions. To ensure your practice complies with federal requirements:

Establish processes to routinely identify the QMB status of Medicare beneficiaries prior to billing for items and services:

States require providers to enroll in their Medicaid systems for claim review, adjudication, processing, and issuance of Medicaid RAs for payment of Medicare cost-sharing.

Correct billing problems that occur. If you bill a QMB member in error, recall the charges (including referrals to collection agencies) and refund the invalid charges they paid.

To learn more:


Action required— Enroll prescribers with the Oregon Health Plan by March 1, 2019

The Oregon Health Authority (OHA) still needs your help to enroll providers who write prescriptions for fee-for-service Oregon Health Plan members by March 1, 2019. 

  • Please share this requirement with your colleagues;
  • Make sure every prescribing provider in your practice is in OHA’s system as an Oregon Medicaid provider; and
  • For any non-enrolled prescribers, enroll them with OHA or their local coordinated care organization (CCO) as soon as possible.

Providing services is voluntary; enrollment does not require a provider to serve all Oregon Health Plan (OHP) members. It does ensure your prescriptions to OHP members will be covered.

How to enroll
To enroll with OHA, 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 CCO claims: Contact the CCO.
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Training and technical assistance

New Provider Web Portal claims search requirements coming February 2019

In early February 2019, the Provider Web Portal at will require users to enter at least one of the following criteria in order to conduct a claim search:

  • Internal Control Number (ICN),
  • Client ID,
  • Tracking Control Number (TCN),
  • Date Paid, or 
  • From Date of Service (FDOS) and To Date of Service (TDOS).

Users will no longer be able to search by Provider ID, Claim Type or Status only.

To learn more about the Provider Web Portal, please visit OHA’s Provider Web Portal page.

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Bill electronically for faster, secure, error-free claims

Go electronic to:

  • Save time, money and paper, and 
  • End issues with wrong forms, wrong ink color, and data entry errors.

It’s easier than you think:

  • The Provider Web Portal at lets you submit claims in real-time 24-hours a day, 7 days a week. You can also create copies of previously submitted claims and edit them for faster billing. All you need is a PIN, an internet connection and current browser.
  • If you submit more than 40 claims per week, electronic data interchange (EDI) may be right for you. Your current office management software may already be set up for EDI.

To learn more:
Read our Electronic Business Practices brochure or visit the Electronic Business Practices page.


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Changes to prior authorization (PA) criteria for hepatitis C direct-acting antivirals (DAAs)

Effective immediately, substance use disorder treatment for patients with substance use disorder, alcohol abuse or illicit injectable drug use is no longer required for Oregon Health Plan coverage of DAA hepatitis C treatment.

Starting March 1, 2019:

  • The Oregon Health Plan will no longer require providers to submit fibrosis test results with PA requests for DAA hepatitis C treatment; providers can request PA of DAA hepatitis C coverage for patients with any stage of fibrosis. 
  • Please see OHA’s March 1, 2019 Hepatitis C DAA PA criteria to learn more.

For any OHP members previously denied DAA coverage due to fibrosis or substance use disorder restrictions who may still need DAA hepatitis C treatment:

  • Please resubmit a PA request to OHA or the member’s CCO. 
  • OHA or the CCO will review the request to see whether the member qualifies for coverage under the updated criteria. Requests for members meeting March 1 criteria may need to be submitted on or after March 1, 2019.
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Rules and program changes


Recent rule revisions

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.