Provider Matters - June 3, 2019

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

June 3, 2019

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In this issue ...

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Important reminders

HERC removes OHP opioid tapering requirement for neck and back pain, effective October 1, 2019

The Health Evidence Review Commission (HERC) voted unanimously to remove requirements for opioid tapering from the Oregon Health Plan guidelines for neck and back pain treatment coverage. The change will be effective October 1.

Meanwhile, the HERC unanimously declined to cover treatments for the five chronic pain conditions that had been under consideration since 2017, citing a lack of evidence of clinical effectiveness for both non-pharmacologic and pharmacologic treatments for those conditions.

To learn more, read OHA’s press release.


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.
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Training and technical assistance

Webinar: Controlling high blood pressure (with no-cost CME)

The Transformation Center invites clinicians who serve Oregonians to a recorded free CME-accredited webinar focused on controlling high blood pressure. The webinar features Dr. Mark Backus, a Bend physician who was named a hypertension control champion by the Centers for Disease Control and Prevention Million Hearts® campaign.

After this 1-hour presentation, participants will be able to:

  1. Review CCO hypertension metric specifications
  2. Explain the implications of the SPRINT blood pressure study and new American Heart Association guidelines
  3. Illustrate the proper body position for taking blood pressure
  4. Identify ways for providers to improve blood pressure control
  5. Share strategies for clinics to improve blood pressure control
  6. Describe how to identify patients who require referral or special testing for their hypertension

No-cost, CME-accredited online tobacco cessation counseling training

  • What: Tobacco cessation counseling online training for all types of providers and care team members. This training is a self-paced, online training that focuses on the Brief Tobacco Intervention and Motivational Interviewing techniques.
  • When: Available now. The training takes approximately 45 minutes. This self-paced course can be started, paused and resumed later as needed.
  • CMEs: This training has been reviewed and is accepted for up to 1.0 prescribed credit from the American Academy of Family Physicians (AAFP). For other licensing boards that may not pre-approve continuing education credits (for example, the Board of Licensed Professional Counselors and Therapists), please submit the certificate of participation to your accrediting body.

Access the training:

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Upcoming changes to fee-for-service authorization of outpatient physical, occupational and speech therapy services

Starting July 1, 2019, OHA will try a new method of review for outpatient physical, occupational and speech therapy services to help therapists start treatment timely.

  • Providers will no longer have to request prior authorization for most therapy services. Instead, they will submit documentation for the current plan of care with the initial claim. If any documentation is missing, OHA will ask providers to submit it to complete the review.
  • Based on this review, OHA will deny or approve payment of claims billed for the current plan of care.

If proven successful, prepayment reviews will continue, using a random sample of claims instead of all submitted claims.

OHA will still require prior authorization for:

  • Services to treat comorbid conditions (see OAR 410-141-0480),
  • Visits that exceed the annual 30-visit limits established in Guideline Note 6 of the Prioritized List of Health Services),
  • Visits longer than 60 minutes, and
  • Any other special circumstances.

OHA originally planned to begin this trial review on June 1, but is delaying the trial to allow more time for providers to prepare for this change.

To be sure you are prepared for this change, review OHA’s fact sheet. It explains the process for claim review and the requirements you must meet.

Billing Medicare-Medicaid claims on the UB-04 paper claim form

If you choose to bill OHA using the UB-04 paper claim form, please complete the form as described in the Institutional Billing Instructions posted on the OHP Billing page.

  • This includes entering “XOVR” in Field Locator 7 only when billing OHA for services provided to OHP members with Medicare coverage.
  • If you do not enter “XOVR” in FL 7, your claim may be denied with a request to bill Medicare first.

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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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

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 issues – Contact Provider Services at 800-336-6016 (Option 5).
  • EDI and the 835 ERA – Contact 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 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.