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Change in Claims Handling for Providers without Active Medicaid IDs

November 10, 2014

As a managed care plan contracted with the Oregon Health Authority’s Medical Assistance Programs (MAP), CareOregon is required to screen providers to rule out fraud, waste and abuse prior to the payment of claims received.

In order to process a claim, the rendering and billing provider NPIs must first be verified as eligible to receive payment by MAP and issued an ID number. Previously, CareOregon held claims for providers while trying to obtain the information required for a Medicaid ID. Due to an increased volume of claims received from providers whose billing and/or rendering NPIs do not have active Medicaid IDs, CareOregon will begin denying claims from providers who do not have these active IDs upon receipt.

Claims denied will have remit codes indicating that their NPI is not matched, and this denial will be followed up with a cover letter and application to complete in order to satisfy the fraud, waste and abuse screening required by MAP. Once the application (and any required supporting documentation) is completed in its entirety and returned to CareOregon, previously denied claims will be reprocessed.

This change impacts both contracted and non-contracted providers submitting claims to CareOregon.