2. Oregon Administrative Rule. OAR 410-120-1140 Verification of eligibility(1) Providers are responsible to verify a person is an Oregon Health Plan (OHP) client with appropriate benefits prior to providing services in order to ensure reimbursement of services rendered. Providers assume full financial responsibility in serving a person who the provider did not confirm with the Division of Medical Assistance Programs (DMAP), is an OHP client who, on the date(s) of service, is enrolled in a benefit package that covers the services rendered..
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1. 1 Eligibility verification Department of Human Services
2. 2 Oregon Administrative Rule OAR 410-120-1140
Verification of eligibility
(1) Providers are responsible to verify a person is an Oregon Health Plan (OHP) client with appropriate benefits prior to providing services in order to ensure reimbursement of services rendered. Providers assume full financial responsibility in serving a person who the provider did not confirm with the Division of Medical Assistance Programs (DMAP), is an OHP client who, on the date(s) of service, is enrolled in a benefit package that covers the services rendered.
3. 3 Resources To verify client medical eligibility, there are 2 options to choose from, they are:
Automated Voice Response (AVR).
MMIS Provider Web portal.
4. 4 Medical care identification Did you notice that the medical care identification is not one of the options?
A new one-time medical care ID card will replace the existing monthly ID.
Each client will have his/her own card.
The medical care ID card does not guarantee coverage.
5. 5 Medical care identification The medical care identification card will only provide:
Date the card was issued
6. 6 Automated Voice Response (AVR)
7. 7 What is AVR? The automated voice response (AVR) is a computer system that gives:
Status of a claim
Status of a prior authorization request
Recent payment or suspended claim information
Benefit limits for eye exams and optical services
Allows providers to complete automated inquiries using a touch-tone telephone.
AVR is available 24 hours a day, 7 days a week.
8. 8 What does AVR provide? The AVR can tell you the following information:
A client’s Medicaid ID number
A client’s date of birth
If a client is eligible on a specific date of service
Which benefit plan the client is eligible for
The client’s copayment requirements
If a service is covered in the client’s benefit plan
If the client is enrolled in a managed care plan
If the client has other insurance coverage
The date of the client’s last vision exam and dispensing
9. 9 Personal Identification Number To access AVR, providers must use the personal identification number (PIN) sent by DHS.
If you have not received your PIN from DHS or you need to have your PIN reset, contact:
DMAP Provider Services
Monday - Friday, 8:00 a.m. to 5:00 p.m.
11. 11 Provider Web Portal
12. 12 Provider Web portal Providers can use the Web portal to:
Verify client eligibility and perform clerk maintenance
Submit, track and view claims
Submit, track and view prior authorization requests
Perform Health Services Commission (HSC) Prioritized List inquiries
View plan of care information
13. 13 Provider Web portal The Web portal is free of charge and accessible 24 hours a day, 7 days a week.
Access to the Web portal requires:
An Internet connection
Microsoft Internet Explorer 6 or 7, or Firefox 2.0
Provider ID and Personal Identification Number (PIN) issued by DHS
14. 14 Getting started In the address field of your Internet browser, type https://www.or-medicaid.gov.
The session “times out” after 20 minutes of inactivity.
Any work or changes that have not been submitted will be lost.
If your session expires, you will receive a message.
15. 15 Web Portal login
16. 16 Home page Select Eligibility.
17. 17 Eligibility verification request
To search for client eligibility use one of three combinations:
1. Client ID and dates of service;
2. Client SSN, birth date and dates of service;
3. Client name, birth date and dates of service.
The Procedure Code field is used to identify service limitations for a specific procedure.
18. 18 Eligibility verification request
Enter one of the 3 combinations as indicated on the previous page and click search.
You can view 13 months of historical eligibility up to today’s date.
The Provider Web portal will not give future eligibility information. All end dates listed in your search results are either the date the client’s coverage ended or the “To DOS” you listed in your request.
19. Eligibility search results displays 6 sections
20. 20 Client information section
The client information section displays basic information about the client.
21. 21 Benefit plan section
The benefit plan section gives information about the client’s benefit plan.
The following codes indicate DHS benefit plans (formerly benefit packages). Disregard all other codes; they are for internal use only.
22. 22 Third party liability (TPL) section Displays specific information about the client’s third-party resources (other insurance).
23. 23 Managed care section
The Managed Care section displays information about which managed care plan or primary care manager the client is enrolled in.
Plan types are:
FCHP - Fully Capitated Health Plan
DCO - Dental Care Organization
MHO - Mental Health Organization
PCO - Physician Care Organization
PCM - Primary Care Manager
24. 24 Lockin section
If the client is required to use a specific pharmacy through the Pharmacy Management Program (PMP), that information will be listed in this section.
25. 25 Service limitation section
This section shows the next available date for a specific service that has limitations according to Oregon Administrative Rules.
26. Open card example
27. Managed care example
28. Client not eligible example
29. 29 Logging off
Be sure to logoff when you are done.
1. Click “Account” from the menu bar.
2. Click “Logoff.”
30. 30 Logoff notify Once logged off, the following message will display.
31. 31 Contact If you need assistance determining client eligibility, or other information accessing the Provider Web portal, contact:
DMAP Provider Services
Monday - Friday, 8:00 a.m. to 5:00 p.m.
32. 32 Thank you!