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Oregon Verification of Eligibility and Coverage

To ensure Division reimbursement of services, providers are responsible to verify the following before rendering services:

    • Client eligibility: That the person is an eligible Oregon Health Plan (OHP) client on the date(s) services are rendered; and
    •  Benefit coverage: That the person is enrolled in an OHP benefit package that covers the services they plan to render.

Providers who do not verify eligibility and benefit coverage with the Division before serving a person shall assume full financial responsibility in serving that person.

The following types of client identification (ID) only list the client’s name, Oregon Medicaid ID number (prime number), and the date the ID was issued. They do not guarantee client eligibility or benefit coverage:

    • The standard ID (called the Oregon Health ID, formerly the DHS Medical Care ID) printed on perforated paper the size of a business card;
    •  Replacement IDs (printed on regular printer paper in case of misplaced originals).

When a person presents a standard or replacement ID, providers must verify client eligibility and benefit coverage through one of the following

    • The Division’s Medicaid Management Information System (MMIS) Provider Web portal;
    • The Automated Voice Response (AVR) telephone system;
    •  Batch or real-time electronic data interchange (EDI) eligibility inquiry (270) and response (271) transactions.

The client may also present one of the following Temporary Oregon Health IDs; both are full-page forms:

    • DMAP form 1086: This document guarantees eligibility and benefit coverage for seven days from the beginning dates of coverage entered in Part 1 of the form. This temporary ID is issued only if the client needs immediate care but their eligibility and coverage information is not yet available for verification. Providers must honor the Temporary Oregon Health ID when within seven (7) days of the beginning date of coverage entered on the form;
    • OHP 3263A: Approval Notice for Hospital Presumptive Eligibility for Medical Coverage: This ID is issued for those who are “presumed” eligible based on certain information and authorizes benefit coverage only on a temporary basis. The OHP 3263A informs the client of the exact date by which the Division must receive their full Medicaid application so that they may be evaluated for ongoing eligibility.

Citation

OAR 410-120-1140

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