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 Updates about fee-for-service claim processing, policy and resources for
Oregon Health Plan providers
September 23, 2019
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Last week, the Oregon Health Authority began outreach to Oregon Health Plan members in Clackamas, Lane, Multnomah, Washington and parts of Douglas, Jackson and Polk counties to let them know they will have an opportunity to choose their CCO for 2020.
Provider resources:
If you serve these areas, visit OHA’s new web page about 2020 CCO changes for providers to:
- Get information about how the changes will affect you, and
- Learn how you can help patients as January 1, 2020 approaches.
The new page is for any provider experiencing changes due to CCO changes in 2020, including the December 31, 2019 closures of Willamette Valley Community Health and PrimaryHealth of Josephine County.
Member resources:
OHP members also have access to a special call center to support them through this transition at 877-647-0027. You can find OHP member mailings, a new video, and other key information on our special “Pick Your Plan” webpages, available in English and Spanish.
If you receive questions from OHP members looking for help and support, you can direct them to our special call center or ohp.oregon.gov.
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The Centers for Medicare & Medicaid Services published Version 37 of the Medicare Severity Diagnosis-Related Group (MS-DRG) and the Long-Term Care DRG files effective October 1, 2019. OHA will not be able to implement these updates by October 1.
When OHA updates the system with the new MS-DRG and LTC-DRG, we will let you know.
Following Medicare's reimbursement rules, the Oregon Health Authority will pay for the following modifiers only for certain procedure codes:
- 80, 81, 82 and AS for codes that have an indicator of "2" in Column U of the "PPRVU" file in the 2019 Medicare Physician Fee Schedule; and for out-of-hospital births billed using procedure code 59409 and Place of Service code 12 (Home) or 25 (Birthing Center).
- 26 for codes with an indicator of “1” or ”6” in Column N of the “PPRVU” file. Codes with indicator “8” are also allowed with Place of Service code 21 (inpatient hospital).
- TC for codes with an indicator of “1” in Column N of the “PPRVU” file.
- SL for administration of state-supplied vaccines, using the vaccine-specific procedure code. Do not use modifier 26. The SL modifier is used to bill for the administration of vaccines provided through the Vaccines for Children program and vaccines provided by public clinics to 317-eligible patients.
Recent rule revisions
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410-141-0520 - Updates the Covered and Non-Covered Services According to the Prioritized List
Sign up to get rule updates via text or email
You can 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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