Jackson County webinar recording, materials now available
On January 15, OHA hosted a webinar with AllCare CCO and Jackson Care Connect for local providers to:
- Learn more about working with their CCOs to coordinate care for Oregon Health Plan members moving to new CCOs in 2020, and
- Participate in a Q&A session with OHA and the CCOs.
You can now view the webinar recording and webinar slides, which also are posted on OHA’s CCO 2.0 provider resources page.
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Timely filing, billing accuracy and documentation requirements
Timely filing: Oregon Administrative Rule (OAR) 410-120-1300(1) requires providers to submit fee-for-service claims within 12 months of the date of service.
- If you intend to submit older claims, double-check the dates of service and submit the claim on paper to Provider Services.
- The Provider Contacts List explains where to send paper claims.
Billing accuracy: OAR 410-120-1280(5) requires providers to submit "true and accurate information when billing the Division," even when delegating the actual billing responsibility to a billing provider. The provider and their biller may not submit any false claims for payment. This includes any:
- Claims for services that were not provided;
- Claims altered as to result in payment for a service that has already been paid; and
- Claims that should be paid by another source, with exceptions. See OAR 410-120-1280(8)(c) to learn more.
Documentation: OAR 410-120-1360 requires providers (or their designated billing service) to "develop and maintain adequate financial and clinical records and other documentation that supports the specific care, items, or services for which payment has been requested."
- OHA will only pay for services that are adequately documented.
- Documentation must support the dates of service, the amounts billed, the specific services provided, who provided the services, and the medical necessity of those services.
- Financial records must indicate that the amount billed OHA was appropriate and that all other resources (e.g., private insurance) were pursued before billing OHA.
- Providers must keep clinical information on file for seven years, and financial records five years.
To learn more about how to ensure your claims meet state and federal requirements, visit the OHP Billing page and the federal Medicaid Program Integrity Education website.
When billing for maternity care using global codes, bill OHA or the CCO based on the mother’s enrollment status on the day of delivery
The code set for maternity care includes options for billing as one global package or billing the prenatal care, delivery, and postpartum care separately.
When billing for these services as a global package and an OHP member’s physical health enrollment changes during the pregnancy:
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If the member is in a CCO on the day of delivery, bill all care to the CCO, even if most or all care occurred prior to the patient’s CCO enrollment.
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If the member is FFS on the date of delivery, bill all care to OHA, even if most or all prenatal care occurred while the member was in a CCO.
- Do not bill both the CCO and OHA.
When billing separately for prenatal, delivery and postpartum care, please continue to bill OHA or the CCO for each type of care based on the mother's enrollment status on the date of service.
Standard guidelines for when to use global billing still apply (refer to the current CPT Handbook).
Oregon’s Electronic Surveillance System for the Early Notification of Community-Based Epidemics (OR-ESSENCE) uses diagnosis and other information from hospital EHR systems to find out what is happening in emergency departments across Oregon before, during and after a public health emergency or disease outbreak.
Better reporting
Thanks to modernized data systems that use ICD-10 codes to find reportable conditions, epidemiologists can now:
- Locate Oregon pesticide poisoning cases in OR-ESSENCE (reported under ICD-10 codes T60 - pesticide poisoning and T59 - toxic effect of chlorine gas, also considered a pesticide), and
- Transfer suspect cases to the Oregon Public Health Epidemiologists’ User System (Orpheus).
Better data
Over 85% of the suspect cases found and transferred from OR-ESSENCE were previously unknown to epidemiologists, helping OHA confirm more pesticide poisoning cases than ever before, and improving public health.
Better health
This success underscores the importance of providers correctly and completely coding for any reportable conditions at discharge. This is especially true for reportable conditions that don’t always have a lab test, such as pesticide poisoning, silicosis, cryptosporidium, and animal bites.
To learn more about the practical applications of OR-ESSENCE data, visit the OR-ESSENCE website.
Free Technical Assistance for Clinics: Alcohol & Opioid Management
The OHA Transformation Center is partnering with the Oregon Rural-based Practice Research Network (ORPRN) to offer clinics free technical assistance for the screening, brief intervention and referral to treatment (SBIRT) CCO incentive metric.
- ANTECEDENT is designed to address unhealthy alcohol use in primary care.
- The PINPOINT Collaborative supports clinics to address chronic pain management and opioid prescribing.
To learn more, read OHA's technical assistance flier. You can also email Alissa Robbins or the ANTECEDENT program.
410-120-1280 - Billing Rules - Adding A New Form Number For A Pharmacy-Specific Agreement To Pay Form (OHP 3166).
To learn more about this form, read OHA's fact sheet about the form and the December fax to Oregon pharmacies.
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