How to Resolve Fee-for-Service Claims

How to Check Claim Status

You can check status online using the MMIS Provider Portal or by reviewing the paper remittance advice.

Learn how to review, adjust or resubmit claims using the portal

Denied Claims

How to resolve denied claims depends on the reason for the denial. Please resolve or appeal denied claims within 18 months of the date of service. After 18 months, there is no appeal option; the only option left is provider write-off.

Correct and resubmit the claim. You cannot void or adjust a denied claim.

Common paper claim errors:

Entering numbers other than the provider's Oregon Medicaid ID ("MCD") number in the billing, rendering, referring or attending provider field of the claim.
On professional claims with TPL, not entering what TPL paid in box 29, or not entering the appropriate adjustment reason code in box 9.
On institutional claims for members with primary Medicare coverage, not entering XOVR in box 7.

Check the member's eligibility and enrollment. If the member is in a CCO, bill the listed CCO.

This means the TPL section of the submitted claim, or fields in the TPL section of the claim, may be blank or incorrect. The claim must include the amount TPL paid and the appropriate adjustment reason code.

Do not enter Medicare information in the TPL section.
Is the TPL on file outdated? Update it at www.ReportTPL.org.
If you do not know all the patient's information you can enter "00000" in the appropriate box.
If you don't know the plan ID for the member's TPL, call Provider Services.
If there is no primary payment, enter the appropriate adjustment reason code on the web or paper claim:

Deductible: 1 (web), UD (paper)
Co-insurance: 2 (web), OT (paper)
Maximum benefits: 119 (web), MB (paper)
Not covered: 96 (web), NC (paper)

Learn more about TPL requirements and tips

All services provided by out-of-state non-contiguous providers require prior authorization.

For in-state services, the combined HSC List Inquiry in the MMIS Provider Portal, Oregon Administrative Rules covering the service, or the Behavioral Health Fee Schedule will list which services require prior authorization (PA).

For medical/dental services, call 800-336-6016. Choose option 3 for help with an existing PA request. Choose option 4 to find out if a specific diagnosis/procedure code pair requires PA.
For applied behavior analysis services, call Acentra Health at 800-562-4620.
For other behavioral health services, call Comagine Health at 888-416-3184. Refer to the Behavioral Health Fee Schedule before calling Comagine.

Learn how request prior authorization

This means the service is not funded according to the Prioritized List of Health Services, or is not part of the member's OHP benefit package.

Verify coverage using the Benefits and HSC List Inquiry in the MMIS Provider Portal.

For members under age 21, Prioritized List coverage does not apply. Request prior authorization for unfunded services. Learn more on the EPSDT page.

For members age 21 or older, you can:

Appeal the denial (see below).
If the service would improve a covered medical condition, submit a request to approve unfunded or comorbid physical health services.

For members with a Medicare replacement (Medicare Advantage) plan:

This coverage is the same as Medicare.
Report this coverage in the Medicare section of the claim.
Do not use the TPL section for this information.

When a member has a Medicare supplement plan:

This coverage is supplemental to Medicare.
Report this coverage in the TPL section of the claim.

This means the claim was submitted more than 12 months from the date of service.

For claims submitted and denied within 12 months of the date of service, you have 18 months from the date of service to resubmit the claim (see Oregon Administrative Rule 410-120-1300). To do this:

Submit as a paper claim with a coversheet.
The coversheet should ask OHA to bypass timely filing limits.
Include the Internal Control Number (ICN) of the original claim as proof of timely filing.
Mail to OHP Provider Services, 500 Summer St NE E44, Salem OR 97301. OR
Send via secure email to OHA.FFSOHPClaims@odhsoha.oregon.gov.

Send a letter stating reasons for the appeal or redetermination. Do this within 180 days of the denial and within 18 months of the date of service. With the letter, attach:

The claim for denied services.
The original denial notice or remittance advice (RA).
Complete documentation that supports covering the service. See Oregon Administrative Rule (OAR) 410-120-1570 to learn more about the types of information to send.

Mail to OHP Provider Services, 500 Summer St NE, E44, Salem, OR 97301 OR

Send via secure email to OHA.FFSOHPClaims@odhsoha.oregon.gov.

Overpaid or Underpaid Claims

You can void or adjust the claim. If you do this, no further action is needed to adjust prior payments. Payment adjustments will automatically show in future remittance advices (RAs).

Paid claims may have zero payments for these reasons:

Rural Health Clinics, Tribal Health Clinics and Federally Qualified Health Centers must include an Evaluation and Management (E/M) code on the first line of the claim.
Clinics set up for Alternate Payment Methodology (APM) may only bill for members listed in the 820 report from their clearinghouse.
For members with TPL as primary, the TPL's primary payment may be more than Medicaid's allowed amount.

If it has been less than one year since the claim's date of service, you can use the MMIS Provider Portal to:

Void the claim or
Adjust the claim to add any other payment information that may cause the claim to pay differently.

If you use an Electronic Data Interchange (EDI) clearinghouse to submit claims, you can void or adjust using your EDI software.

For older claims, you can submit the OHP 1036 form. On the form, you can:

Request to void the claim or
List the specific changes needed to adjust the claim.

When to Send a Check

If you cannot void or adjust an overpaid claim, you can send a check made out to “Oregon Medicaid." It can take up to four months to process your check and have the refund show up on your RA.

Include a letter stating what the check is for.

List the Internal Control Number for each claim.
If the check is for more than one claim, list how much money goes to each claim.

Attach a copy of the original RA.

Mail the check, letter and RA copy to:

ODHS/OHA Receipting
500 Summer St NE, 4th Floor
Salem OR 97301

Quick Links

MMIS Provider Portal

How to Read the Remittance Advice

How to Read the Leverage Claims Payable - Not Paid Section of the Paper Remittance Advice

Common Billing Errors

Fee-for-Service Fee Schedule

MMIS Prioritized List Inquiry

OHP 1036 Individual Adjustment Request Form

OHP 3085 Request for Claim Review (Appeal Form)

Need Help?

Call or email Provider Services (800-336-6016, option 5)

How to Resolve Fee-for-Service Claims

How to Check Claim Status

Denied Claims

Technical errors, such as coding, typos, incorrect completion of paper claims

Common paper claim errors:​​​​

Denied due to managed care

Denied due to TPL/primary coverage

Prior authorization denials

Denied for non-covered service

Denials for services to Medicare members

Timely filing denials

To appeal denied claims:

Overpaid or Underpaid Claims

Zero payments

To resolve claims less than a year old:

To resolve claims more than a year old:

When to Send a Check

What to send

Where to mail

Quick Links

Need Help?

Common paper claim errors: