 In this issue …
Starting September 3, 2019, the Oregon Health Authority (OHA) will deny prescriptions written by non-Oregon Health Plan (OHP) providers
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.
Starting September 3, 2019, OHA will deny prescription claims that do not contain the National Provider Identifier (NPI) of an active, enrolled Oregon Medicaid provider.
OHA is writing approximately 1,900 OHP members about this change and asking them to make sure future prescriptions are written by enrolled providers.
In the meantime, please help OHA’s outreach efforts by:
- Sharing this requirement with your colleagues;
- Making sure every prescribing provider in your practice is in OHA’s system as an Oregon Medicaid provider; and
- Enrolling any non-enrolled prescribers with OHA or their local CCO as soon as possible.
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.
Questions?
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About prescriber enrollment: Contact Provider Enrollment at 800-336-6016 (Option 6) or provider.enrollment@dhsoha.state.or.us.
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About fee-for-service prescription claims: Contact the Pharmacy Call Center at 888-202-2126. This number is for providers only.
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About CCO claims: Contact the CCO.
Concierge care and OHP coverage
Services that would be covered by OHP during normal business hours are still covered by OHP when accessed outside of normal business hours, as long as the services are provided by active, enrolled OHP providers.
Membership-based “concierge” (also known as “direct primary care”) services require members to pay a flat monthly or annual fee for 24/7 access to primary care.
- If these providers participate in Medicare or Medicaid, they cannot bill the member for Medicare- or Medicaid-covered services or any membership fee associated with “concierge” or “direct primary care.”
- If these providers do not participate in Medicare or Medicaid, they can bill the member for the membership fee and services they provide, even if the same services would have been covered through a participating provider.
To learn more about the do’s and don’ts of billing OHP members, review OHA’s fact sheet.
Hospice services do not require prior authorization
OHA has received several requests for prior authorization (PA) of hospice services, which do not require PA.
To serve members timely and help reduce the number of unnecessary PA requests submitted to OHA, please submit PA requests only for services that require PA. To do this:
- Use the Prioritized List inquiry in the Provider Web Portal at https://www.or-medicaid.gov. You just need the client’s 8-digit ID, your provider ID, the procedure code, diagnosis code, date of service and claim type.
- If the service requires PA, there will be a “Yes” in the “PA required field.
- If the service is covered by the client’s CCO, there will be a “Yes” in the “Managed Care” field. In this case, contact the CCO to find out if the service requires PA.
To learn more about requesting PA from OHA, visit the Prior Authorization page.
No updates at this time.
2019 changes to fee-for-service substance use disorder treatment codes
OHA has updated its claim system and the OHP Behavioral Health Fee Schedule with changes to the units and daily limits for SUD HCPCS codes H0005 and H0015, effective January 1, 2019.
- These updates will also be available in the upcoming July 2019 Behavioral Health fee schedule.
Bill OHP for preventive medicine counseling services
As an OHP provider, do you spend extra counseling time to help members understand the risks and benefits of preventive medicine services, such as vaccinations?
If so, please remember to bill OHA or the member’s coordinated care organization for preventive medicine counseling. This is a covered benefit for OHP members.
The following procedure codes may be considered if appropriate for your patients' encounters:
- 99401: Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes
- 99402: 30 minutes
- 99403: 45 minutes
- 99404: 60 minutes
Use only black ink on paper claims and medical documentation
To ensure that OHA captures all information entered on paper claims and supporting documentation, please use black ink only. Do not use other colors, such as blue or red.
- On “red ink” forms such as the CMS-1500 claim form, the red ink is not recognized by our imaging system.
- Blue ink often comes across much lighter than black ink, making it difficult to capture the writing on the claim or supporting documentation.
- In both cases, the claim comes across as incomplete and will be denied for missing or invalid information.
To avoid these issues, you can also bill OHA electronically using the Provider Web Portal at https://www.or-medicaid.gov. All you need is a current internet browser and internet connection. To learn more, visit the OHP Electronic Business Practices page.
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.
Recent rule revisions
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410-172-0705, 410-172-0730 - Standardized Per Diem Habilitation Rates for Mental Health Residential Treatment Programs
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410-120-0006 - Calculation and Liability of Overpayments and Updating Authorized Representative Rules for Integrated Eligibility
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410-121-0030 - Amending PDL May 23, 2019 DUR/P&T Actions
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410-021-0040 - Amending Prior Authorization Approval Criteria Guide
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410-136-3370 - General Requirements for GEMT
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410-121-0030 - Amending PDL March 21, 2019, DUR/P&T Action
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410-141-0520 - Updates the Covered and Non-Covered Services According to the Prioritized List
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410-170-0110 - Updated Behavioral Rehabilitation Services (BRS) Rate Table Incorporated by Reference
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410-050-0861 - Type A/B Hospital Assessment Rate Decrease
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410-131-0080, 410-131-0120, 410-131-0160, 410-129-0020, 410-129-0060, 410-129-0070, 410-129-0080, 410-129-0200, 410-129-0220 - Adding Prepayment Review Criteria to Address Prior Authorization Backlog
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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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.
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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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