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Updates about claim processing, policy and resources for
Oregon Health Plan providers
July 31, 2019
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In this issue…
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2020-2024 coordinated care updates
The Oregon Health Authority (OHA) announced its intent to award 15 organizations contracts to serve as coordinated care organizations (CCOs) for the Oregon Health Plan’s nearly 1 million members.
- Eleven of the organizations are approved to receive five-year contracts, and four organizations are approved to receive one-year contracts. Awardees will now be evaluated for their readiness to deliver the services promised in their applications.
- Successful awardees will sign their contracts, totaling more than $6 billion for the 2020 contract year, in the fall. The new CCO contract services start January 1, 2020.
OHA is also holding a series of Rule Advisory Committees (RACs) to review draft changes to the Oregon Administrative Rules that will govern CCOs effective January 1, 2020. To learn more about the RACs and review the drafts in development, visit the CCO 2.0 RAC information page.
Enroll all prescribers with OHA to ensure continued prescription access
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. To ensure prescriptions to OHP members are covered, please:
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.
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Webinar: Controlling high blood pressure - CMEs only available for a few more months
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.
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When: Available on demand through September 20, 2019.
After this 1-hour presentation, participants will be able to:
- Review CCO hypertension metric specifications
- Explain the implications of the SPRINT blood pressure study and new American Heart Association guidelines
- Illustrate the proper body position for taking blood pressure
- Identify ways for providers to improve blood pressure control
- Share strategies for clinics to improve blood pressure control
- Describe how to identify patients who require referral or special testing for their hypertension
Free, quick online tobacco cessation counseling training (with CME)
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What: This short online course will improve your care team’s ability to help patients quit tobacco. The course focuses on brief tobacco intervention and motivational interviewing techniques.
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Who: All members of the care team committed to supporting their patients to quit tobacco.
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When: The course is available through November 30, 2019. It is self-paced and takes approximately 45 minutes. The course can be started, paused and resumed later as needed.
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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.
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Access the training: https://tcrc.rapidlearner.com/3462253711
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Questions? Please contact Anona Gund (Anona.E.Gund@dhsoha.state.or.us or 971-673-2832)
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Individual Adjustment Request mailbox closing September 1, 2019
On September 1, 2019, OHA is closing PO Box 14952. This mailbox is used to mail hardcopy Individual Adjustment Requests to OHA.
On and after September 1:
- Please mail paper adjustment requests to 500 Summer St NE E44, Salem OR 97301.
- You can also submit electronic requests through the Provider Web Portal at https://www.or-medicaid.gov.
Resources about adjusting claims are available on the OHP Billing Tips page.
Fee-for-service (FFS) prior authorization updates
New Provider Clinical Support manager
OHA’s Provider Clinical Support Unit reviews all FFS physical health prior authorization requests. On June 3, 2019, OHA welcomed the unit’s new manager, Brenden Magee. Transferring from his career in correctional health care, Brenden is a Registered Nurse with a Bachelor of Science in Nursing degree and Master of Health Administration degree, both from Ohio University.
Avoid delays by submitting only required documentation
When requesting prior authorization for any services, please ensure that you are submitting required documentation only.
- Sending inadequate documentation will result in follow-up requests for the correct documentation.
- Sending excessive documentation (e.g., the patient’s full medical record) will result in delays as staff then need to read the full record to determine if required documentation is present. This may still result in a follow-up request for the specific documentation required for the requested service.
Submitting only the documentation required by the program-specific Oregon Administrative Rules will help to ensure that your requests are processed efficiently, reducing overall wait times.
If you have questions about how to submit prior authorization requests to OHA, please refer to OHA’s Prior Authorization page.
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Changes to FFS opioid coverage criteria effective October 1, 2019
Beginning October 1, 2019, OHA will implement the following changes to FFS opioid coverage criteria:
- Initial prescriptions of short-acting opioids for acute conditions in patients new to opioid therapy will be restricted to 7 days or less. Prescriptions for more than 14 days in a 90-day period will require prior authorization (PA).
- Initial prescriptions for any long-acting opioid will require PA.
These restrictions do not affect:
- Patients with existing FFS prescriptions for chronic opioid therapy. OHA will approve their therapy for one year (through September 30, 2020).
- PA can be requested for patients who require continued chronic opioid therapy beyond September 30, 2020.
- Patients with sickle cell disease, cancer pain, or end-of-life pain needing palliative care. However, PA may initially be required.
Current FFS PA criteria for short- and long-acting opioids are available at www.orpdl.org/drugs under the “Analgesics” category.
Why is this happening?
Section 1004 of the SUPPORT Act adds subsection 42 U.S.C. 1396a(oo)(1) to federal Medicaid law effective October 1, 2019. It requires states to implement safety edits that indicate when Medicaid patients are prescribed subsequent fills of opioids in excess of state limitations.
OHA will continue to work with the Health Evidence Review Commission and the Pharmacy & Therapeutics Committee to guide future evidence-based coverage policies for pain management and opioid prescribing.
Provider resources
OHA offers many resources for providers who want to learn the latest information about pain management and opioid treatment, including:
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Recent rule revisions
None at this time.
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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