Provider Matters - March 29, 2019

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

March 29, 2019

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In this issue ...

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Important reminders

Proposed changes to Oregon Health Plan chronic pain benefit coverage on hold—Potential conflict to be reviewed independently to ensure integrity

The Health Evidence Review Commission (HERC) had planned to review proposed changes to chronic pain benefit coverage this month. However, after learning of a potential conflict of interest, Oregon Health Authority (OHA) Director Patrick Allen has put discussion of the proposal on hold so that OHA can seek an independent review.

  • The review will ensure no potential conflicts of interest compromised the way the chronic pain benefit proposal was developed for the HERC’s consideration.
  • Director Allen cited objectivity, integrity and transparency as reasons behind his decision.

Director Allen also asked Dr. Dana Hargunani, OHA’s chief medical officer, to conduct a full review of the HERC’s conflict of interest disclosure process. In his statement, Director Allen said, “It is vital for the Oregon Health Plan to cover safe and effective therapies to help people reduce and manage chronic pain. Yet it is also vital that Oregonians have full confidence in the decisions the HERC makes to assess the effectiveness of health care procedures.”

Read the rest of Pat’s statement in his recent press release.

Action required— Enroll prescribers with the Oregon Health Plan

OHA will not set a new effective date for the prescriber enrollment requirement for fee-for-service prescription claims until more prescribers enroll with OHA or their local coordinated care organization (CCO). This is to ensure continued prescription coverage for as many OHP members as possible.

Despite continued outreach, too many prescribers remain unenrolled. Please help OHA’s outreach efforts by:

Enrollment does not require any provider to start serving OHP members. However, it does ensure that the prescriptions they write for OHP members are 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

How to verify managed care enrollment of Oregon Health Plan members

OHA continues to receive claims for services that should be billed to the member’s CCO. When this happens, OHA will deny the claim for you to resubmit to the CCO.

To avoid delays in claim processing for services to CCO members:

  • Verify CCO enrollment.
  • Follow the CCO’s policies and procedures, including their specific billing and authorization requirements.

The “Managed Care” section of the Provider Web Portal Eligibility Verification Screen shows any CCO, dental plan, or mental health plan the member is enrolled in.

  • “CCOA” plan type means the CCO covers all health care (behavioral, dental and physical health).
  • “CCOB” plan type means the CCO covers behavioral and physical health; OHA covers dental care.
  • “CCOE” plan type means the CCO covers behavioral health only. OHA covers dental and physical health care. (Some members may be enrolled with a “DCO” plan type. In these cases, the dental plan covers dental care.)
  • “CCOG” plan type means the CCO covers behavioral health and dental care. OHA covers physical health care. (Some members may be enrolled with an “MCO” plan type. In these cases, the mental health plan covers behavioral health care).
  • If no plans are displayed, OHA covers all health care.

To learn more about verifying member eligibility and enrollment, visit the OHP Eligibility Verification page.

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Paper claim reminders

If you choose to bill OHA using paper claims, please submit them as described in the billing instructions posted on the OHP Billing page. This includes:

  • Mailing paper claims to the PO Boxes listed in the guides and the Provider Contacts List. Do not mail or fax claims to local DHS offices.
  • Entering all fields as described in the guides, including correct alignment in the Client name, Client ID, and Date of Service fields on line 1 of professional claims; and the Type of Bill, Statement From and Through Dates, and Patient Name fields on institutional claims.
  • Using commercially available claim forms (not facsimiles or photocopies).

To avoid these issues, you can also bill OHA electronically using the Provider Web Portal at All you need is a current internet browser and internet connection. To learn more, visit the OHP Electronic Business Practices page.

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No updates at this time.

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Rules and program changes

Recent rule revisions

  • 410-120-0006 – Amending OAR 410-120-0006 to Comply with Chapter 461 for Overpayment, Personal Injury Liens, Estates Administration
  • 410-121-0030 - Amending Preferred Drug List (January 24, 2019 DUR/P&T Action)
  • 410-121-0040 - Amending Prior Authorization Approval Criteria Guide
  • 410-123-1220 - Update citation for January 1, 2019, in Coverage per the Prioritized List of Health Services
  • 410-165-0000, 410-165-0040, 410-165-0080, 410-165-0100, 410-165-0140 - Update Rules Governing Payment for the Medicaid EHR Incentive Program
  • 410-172-0720 – Adjusted Criteria for Admissions to Secured Residential Treatment Facilities (SRTF)
  • 410-200-0111 - Aligning OAR 410-200-0111 re: Authorized Representatives with DHS OAR 461-115-0090
  • 410-200-0315 - Income Eligibility Guidelines for OCCS Medical Programs

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.