Learn about Fee-for-Service Billing
Also refer to the
provider guidelines for your program and the
General Rules.
Find mailing addresses for fee-for-service paper claims and more in the
Provider Contacts List.
Do you want to review, adjust, resolve or appeal a claim you already billed OHA? Visit OHA's Claim Resolution page.
Before You Bill
Use Oregon Administrative Rules, Priortized List, Guideline Notes, and other guidance related to the service.
- See if any limitations, restrictions or exclusions apply.
- See if the patient's OHP benefit package covers the service.
- The Keys to Success guide explains each step to consider.
OHP covers procedures provided in the scope of the provider's licensure or certification.
- A provider can look to their licensure or certification to see if it allows them to perform the procedure in question.
- The Behavioral Health Fee Schedule also lists allowed rendering provider types for many behavioral health services.
Records must support the fee or rate you bill. Records should include the date of service; who provided the service; and any other documentation required by rule, provider guidelines or contract.
In most cases, OHP (Medicaid) is the payer of last resort. For patients with third-party liability (TPL; other insurance, including Medicare), OHA pays the maximum allowed rate in the fee-for-service fee schedule, less the TPL payment but not to exceed the maximum allowable rate or fee.
OHA Billing Requirements
For all providers subject to NPI, you must include their NPI on related claims.
- When billing OHA, make sure the NPI you bill under is the same one you have reported for your Oregon Medicaid ID.
- The NPI on the claim must be actively enrolled for the dates of service on the claim.
To check your NPI information, contact Provider Enrollment (800-336-6016, option 6).
To look up the NPI of the ordering, referring, or rendering provider for a claim, use the NPI Registry.
For fee-for-service (open card) claims:
OHP
PO Box 14955
Salem, OR 97309
For coordinated care organization (CCO) claims:
Contact the CCO.
Billing OHP as Secondary Coverage
Enter the amount paid on the web or paper claim.
- Web: TPL Amount field of claim header
- CMS-1500: Box 29
- UB-04: Field Locator (FL) 54B
If there is no primary payment, enter the appropriate adjustment reason code (ARC) on the web claim. For paper claims, just the two-digit third-party resource (TPR) code.
- Web: Adjustment Reason Code field of TPL section
- CMS-1500: Box 9
- UB-04: Field 80
If primary denies for max benefits, submit claim on paper. Attach the primary's EOB.
For electronic claims:
Medicare clearinghouses may transmit the Medicare information as TPL or not include Medicare details in the Medicare section of electronic claims. You can review such claims in the Provider Portal.
For professional claims:
Bill using the OHP 505 (Medicare-Medicaid) form. Report Medicare payment in these fields:
- 22g. Charges Billed to Medicare
- 22h. Medicare allowed charges: enter in how much Medicare paid either towards co-insurance, deductible, or the total bill
- 25. Total Medicare Payment (what Medicare paid towards the bill, not the co-insurance or deductible)
For institutional claims:
Enter XOVR in FL 7. In FL 54 (Prior Payments), list any payments you received from other resources for the Statement Covers Period. Use the line that corresponds with the payer entered in FL 50.
- Line A for payments received from Medicare.
- Line B for any payments from other third party payers.
- Line C – Always leave blank. Do not list write-offs, what Medicaid previously paid, or copayments.
If the client has other medical coverage, enter the appropriate ARC or TPR code in FL 80.
- Deductible: 1 (web), UD (paper)
- Co-insurance: 2 (web), OT (paper)
- Maximum benefits: 119 (web), MB (paper)
- Not covered: 96 (web), NC (paper)
Handbooks, Tips, and Step-by-Step Guides
Learn about fee-for-service claim processing, how to bill OHA on paper, and how to bill using the Oregon Medicaid Provider Portal. Use the search field to find resources by topic, keyword or document name. For example:
- Enter "portal" for resources about submitting web portal claims.
- Enter "paper claims" for resources about submitting paper claims.