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

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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:

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.

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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.

The following CPT codes are covered under the Vaccines for Children Program:
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
2 All children ages 36–59 months and all medically high-risk children ages 60 months to 18 years as defined by the Public Health Immunization Program, including contacts to high-risk household members
3 Use when 90700 and 90648 are given combined in one injection
4 All children ages 5 through 18 years who are contacts to high-risk household members, as defined by the Public Health Immunization Program

CMS (formerly HCFA) 1500

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We have exciting news to share. ODS is changing its name to Moda Health.

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