Initial therapy for newer antineoplastic drugs will require prior authorization effective October 1, 2020
Beginning October 1, 2020, OHA will require prior authorization (PA) of fee-for-service (FFS) pharmacy and physician-administered claims for new antineoplastic therapy using drugs approved by the Food and Drug Administration (FDA) after 2007.
- Current FFS PA criteria and a complete list of medications which will require PA are available at orpdl.org/drugs under “Antineoplastics, Newer.”
- The intent of this policy is to ensure medically appropriate use of newer antineoplastic agents.
These restrictions do not affect:
- Inpatient claims for patients admitted to the hospital.
- Urgent, life-threatening oncology emergencies. However, documentation of the emergency may be required in order to process payment.
- Continuation of a current, ongoing oncology regimen. However, a PA may initially be required to document previous therapy.
Contact for applied behavior analysis authorization requests
While many fee-for-service behavioral health services for Oregon Health Plan members are now authorized by Comagine Health, KEPRO is still the contact for requesting authorization of applied behavior analysis services.
Please continue to use KEPRO's assessment and authorization forms, and submit them to KEPRO to request fee-for-service authorization of ABA services.
If you have questions about ABA:
As we work toward reopening Oregon, we want to make sure you have the resources you need to keep informed, healthy and safe. If you have any questions about OHP and COVID-19, please let us know.
Updates for Oregon Health Plan providers
Please continue to refer to the Oregon Medicaid COVID-19 Provider Guide for information related to OHP coverage of testing, screening, treatment and telemedicine services; OHP eligibility; and other information and resources related to providing and billing for covered services during COVID-19.
Updates for all health care providers
The Planned Out-of-hospital Birth Coverage Guidance and corresponding Prioritized List of Health Services changes (effective 10/1/2020) were approved at the 8/13/2020 Health Evidence Review Commission meeting. Please see blog page for full documents.
The Health Evidence Review Commission has also published the pending 10/1/2020 Prioritized List of Health Services. Please see our website for all files and details.
Questions?
Please email HERC.Info@dhsoha.state.or.us.
Verify CCO enrollment before scheduling or providing services
Most OHP members are enrolled in a CCO that manages their physical, oral and behavioral health care. When serving OHP members, providers must verify both the member's OHP eligibility and current CCO enrollment for the date of service.
When providers do not verify CCO enrollment when scheduling follow-up appointments or referrals:
- Members may be incorrectly referred to a provider outside the CCO's network, or
- The provider will bill OHA for services that should be billed to the member's CCO. When this happens, OHA will deny the claim for the provider to resubmit to the CCO.
To avoid delays in claim processing for services to CCO members:
- Verify the member's CCO enrollment before scheduling or providing services.
- Follow the CCO’s policies and procedures, including their specific billing and authorization requirements.
- If the member is not enrolled with the CCO you work with, do not schedule an appointment or provide services. Refer the member to their CCO for next steps.
How to check for current CCO enrollment
The “Managed Care” section of the Provider Web Portal Eligibility Verification Screen shows any CCO, dental plan, or mental health plan the member is enrolled in.
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“CCOA” plan type means the CCO covers all health care (behavioral, dental and physical health).
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“CCOB” plan type means the CCO covers behavioral and physical health; OHA covers dental care.
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“CCOE” plan type means the CCO covers behavioral health only. OHA covers dental and physical health care. (Some members may be enrolled with a “DCO” plan type. In these cases, the dental plan covers dental care.)
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“CCOG” plan type means the CCO covers behavioral health and dental care. OHA covers physical health care.
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If no plans are displayed, OHA covers all health care.
Trillium is now serving OHP members in the Portland area
Trillium Community Health Plan has expanded its service area to include Clackamas, Multnomah and Washington counties.
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Members can reach out to OHP to change plans. Members can call 800-273-0557 or use ONE.Oregon.gov to change their CCO plan. OHP will not move anyone or match members to a plan based on provider relationships. Plan changes must be requested by the member.
- Members can use the CCO Plans Comparison Tool to compare plans, find provider directories and other important information.
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CCO enrollment for Trillium follows the regular schedule. If a member is new to OHP or new to the service area, enrollment will be scheduled next weekly. For established members who are changing plans, enrollment starts on the first of the next month.
Interested providers should contact Trillium directly for provider enrollment information or questions.
Medicaid Program Integrity resources for dental professionals
The federal Medicaid Program Integrity website now has training and education materials specifically for dental providers, including:
To learn more and find other resources, visit the Medicaid Program Integrity website.
Free training to become a qualified health care interpreter
OHA's Office of Equity and Inclusion is sponsoring a free, online 64-hour training series for community members, providers and staff who live or work in Ontario and surrounding communities in Eastern Oregon. Applicants must commit to completing all parts of the training series (listed below):
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Introduction: October 9, 2020, 9 a.m. to 5 p.m.
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Online study: October 9 through October 26, 2020 (32 hours)
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Skills and practice: October 26 through October 28, 2020 (24 hours)
Registration ends on Sept. 15, 2020. Seats are limited and priority goes to people who live or work in Ontario and neighboring cities.
To learn more about this training, please email Edna.Nyamu@dhsoha.state.or.us.
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410-121-0030 and 410-121-0040 - Amending Preferred Drug List and Prior Authorization Approval Criteria Guide
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410-123-1245 - Suspends the “Incentive” for Oral Health Prevention Fee-for-Service Program
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410-130-0610 - Amends Medical-Surgical Program Rules For Telemedicine To Assure Access To Medically Necessary Services
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410-141-3566, 410-141-3830 - Telehealth Updates to Prioritized List and CCO Telemedicine/Telehealth Payment Parity Requirements
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OAR 410-141-3830 - Updates to the Prioritized List of Covered Health Services to Improve Access to Telehealth
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