Provider Matters - April 30, 2019

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

April 30, 2019

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In this issue ...

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Important reminders

Everyone who writes prescriptions for Oregon Health Plan (OHP) members must enroll with OHA or their local coordinated care organization (CCO)

Federal Medicaid program integrity regulations require all providers who write prescriptions for Medicaid members to be enrolled as a Medicaid provider in the member’s state. Otherwise, Medicaid cannot cover the prescription. This is true even if the provider is enrolled as a Medicaid provider in a different state.

Despite continued outreach about this requirement, too many prescribers remain unenrolled. Please help Oregon Health Authority (OHA) 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.


Contractor hired for independent review of proposed changes to OHP chronic pain benefit coverage

OHA has hired Washington-based Aggregate Analytics Inc. to conduct a third-party review of proposed changes to OHP’s chronic pain benefit coverage.

The proposal, which is under consideration by the Health Evidence Review Commission, would:

  • Add coverage for five conditions: chronic pain due to trauma, other chronic procedural pain, other chronic pain, chronic pain syndrome and fibromyalgia;
  • Expand access to prescription opioids for four of these conditions;
  • Add coverage for alternative therapies such as acupuncture, physical therapy and cognitive behavioral therapy; and
  • Cover supportive, individualized opioid tapers if the patient has fibromyalgia or their prescribed dosage exceeds Oregon’s opioid prescribing guidelines.

To learn more, read OHA’s press release.

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Training and technical assistance

Enter contact information on Provider Web Portal prior authorization requests

When entering a prior authorization request through the Provider Web Portal at, please be sure to include your contact information in the PA text box. Then the reviewer can contact you if additional clarification or information is required.

To learn more about submitting prior authorization requests to OHA, visit

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Completing CMS-1500 paper claims

If you choose to bill OHA using paper claims, please submit them as described in the Professional Billing Instructions posted on the OHP Billing page. For professional (CMS-1500) claims, this includes entering:

  • The “From” and “To” dates of services for all line items in field 24A.
  • The billing provider’s 10-digit NPI in field 33A.
  • The billing provider’s 5- to 9-digit Oregon Medicaid ID number in field 33B. Do not enter other numbers, such as NPI taxonomy, in this field.

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.


Do not bill OHA for services covered by the member’s CCO

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.

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

To learn about CCO requirements, contact the member’s CCO.

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Please enter prescriber’s NPI on all prescription claims

OHA is reaching out to all prescribing providers who are not enrolled with OHA or a local CCO.

  • OHA has found many claims with other numbers (such as alphanumeric numbers or “999999”) in the prescriber ID field.
  • OHA cannot use these numbers to verify the prescriber’s Medicaid status, identity or contact information to reach out to the prescriber.

To help OHA identify all providers writing prescriptions for Oregon Medicaid members, please include the prescriber’s 10-digit NPI on every prescription billed to OHA. Paper claims also require the Oregon Medicaid ID.

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Rules and program changes

Recent rule revisions

  • 410-121-0030 – Amending PDL March 21, 2019, DUR/P&T Actions
  • 410-121-0040 – Amending Prior Authorization Approval Criteria Guide

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.