OHP claims and appeals
NDC codes required beginning July 1, 2011
Starting with dates of service July 1, 2011, and after, National Drug Code (NDC) information will be required on all physician-administered drug claims billed to Moda Health for Oregon Health Plan patients. This new requirement applies to all professional and outpatient hospital claims, whether billed electronically or on paper. NDC information is not required on inpatient claims. In addition to the CPT/Healthcare Common Procedure Coding System (HCPCS) code, each physician-administered claim must include the NDC code and unit of measure for the drug billed and the actual metric decimal quantity administered. If this information is missing or invalid, the claim will be denied. Providers must resubmit the claim with the required NDC information or correct number of units.
For more information regarding this requirement and billing instructions, please visit the Department of Health Services website.
The Prioritized List
The Oregon Health Services Commission maintains a list of condition and treatment pairings known as the List of Prioritized Health Services. These pairings have been ranked by priority from most important to least important and subsequently assigned a line number from one to 680. Services prioritized as most important are funded by the state. The funding level is set at a line designated by the state. This means any pairing that occurs above the line is considered funded. Any pairing that occurs below the line is not funded. Below the line services are typically categorized as treatments that do not have beneficial results, treatments for cosmetic reasons and conditions that resolve on their own.
The Oregon Health Plan and Moda Health cover all funded services.
Getting started
To verify whether a service is covered by Moda Health, and to find out where the line is currently set, check the List of Prioritized Services. You can access the list for free by visiting the DHS website under Current Prioritized List. In addition to the list, DHS has also provided a searchable index to assist you with locating which line(s) a condition or a treatment is listed.
Important to know
Due to legislative decisions, the funding line is subject to change. For the most current information, be sure to check with either DHS or Moda Health.
Treatment may be covered for one condition but not covered for another. For example, arthodesis may be covered for a dislocation but not covered for an anomaly. Remember, the pairing of the condition with the treatment determines which line the service is on.
The List of Prioritized Health Services applies to both the Plus and Standard benefit packages. However, the Standard plan is further restricted by the Limited Hospital Benefit. More information on the Limited Hospital Benefit can be found at:
http://www.dhs.state.or.us/policy/healthplan/guides/hospital/main.html
Reasons for denied or returned claims
A Clean Claim means a claim that has no defect, impropriety, lack of any required substantiating documentation or particular circumstance requiring special treatment that prevents timely payment in accordance with the Member's Health Benefits Plan and this Agreement.
A Clean Claim shall not include those claims which require coordination of benefits and third party liability issues until receipt of Explanation of Benefits from primary carrier or claims, which are being reviewed by the Medical Director, Medical Consultant or Peer Review for medical necessity.
A Clean Claim shall accurately reflect billed Charges. "Substantiating Documentation" includes, but is not limited to:
- Legible claim form CMS UB 92, CMS 1500 or other required forms
- Full name of patient/OHP member
- OHP member's date of birth
- OHP member's recipient ID number
- Date(s) of service
- Place of service
- CPT procedure code
- Modifier(s) if applicable
- Line item and total charges
- Quantity of units of service
- ICD-9 CM diagnosis code (to the highest specificity)
- Physician's name and address
- Physician's Tax ID Number (TIN)
- Physician's OMAP ID number
- Outpatient hospital services
- Bill type
- Admission date and time
- Discharge date and time
- OMAP billing number for facility
- Revenue center code
- Date of service for each line item
- Quantity of units of service
- Line item charges
- ICD-9 CM diagnosis code (to the highest specificity)
- CPT HCPC code
- Attending provider OMAP provider number
- Inpatient hospital devices and inpatient nursing facilities
- Bill type
- Admission date and time
- Discharge date and time
- OMAP hospital/nursing facility billing provider number
- Type of admission code
- Patient discharge status code
- Date of service (dates of admission through discharge)
- Dates of service through discharge except continuous stay nursing facility clients (use the last day of the month or the discharge date)
- Revenue center code(s)
- Line item charge(s)
- Total charge
- ICD-9 CM diagnosis code (to the highest specificity)
- ICD 9 CM procedure code when a procedure is performed
- Attending physician OMAP provider number
- Written referral, if applicable
A Clean Claim shall not include those claims which require coordination of benefits and third party liability issues until receipt of Explanation of Benefits from primary carrier or claims, which are being reviewed by the Medical Director, Medical Consultant or Peer Review for medical necessity.
Vaccines for Children Billing
The Vaccines for Children (VFC) Program is a federal program that provides free immunizations for children age 0–18 years.
Moda Health does not reimburse for the cost of vaccine serums covered by the VFC Program. Providers should bill Moda Health only for the administration of the vaccines covered under the VFC Program.
Providers should bill the specific immunization CPT code with modifier 26 or SL, which indicates administration only. Providers should not bill for the administration of these vaccines using CPT codes 90465-90474 or 99211 (immunization administration codes).
Moda Health is unable to reimburse providers who do not participate in the VFC Program for the cost of the serum. Providers not participating with the VFC Program can direct their patients to the County Health Department to receive the vaccines covered under the program. A County Health Department can bill Moda Health for the administration of the vaccines.
| 90633 | 90634 | 90645 |
| 90647 | 90648 | 90649 |
| 906551 | 906562 | 906571 |
| 906582 | 906604 | 90669 |
| 90680 | 90700 | 90702 |
| 90704-8 | 90710 | 90713 |
| 90714 | 90715 | 90716 |
| 907213 | 90723 | 90732 |
| 90733 | 90734 | 90743 |
| 90744 | 90748 | 90749 |
| S0195 | ||
1 All children ages 6–35 months |
||
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