Provider support

You can review member eligibility, authorization status, claim status, and more in our provider portal.

Visit our provider portal tutorials page to:

• Learn more about provider portal functions, login and account set-up
• Access tutorials on how to use and navigate the portal
• Learn more about recent enhancements such as secure messaging and direct data entry for claims

Please call Provider Customer Service at 503-416-4100 or 800-224-4840. Press option 3 for provider.

CareOregon notifies our provider network occasionally with alerts or urgent communications.  To sign up for these alerts, email careoregonalerts@careoregon.org and include your name and job title. 

Send changes or updates regarding your clinic, facility, or other demographic information to ProviderDataUpdates@careoregon.org.

View our team assignments list to find your specialist. Fax us at 503-416-1478 or 800-874-3916. 

CareOregon takes fraud, waste and abuse very seriously. If you suspect that benefits aren't being used correctly or want to report a case of waste, abuse or fraud, please contact EthicsPoint at 888-331-6524. You also can file a report online at  EthicsPoint.

Providers should report any instance of FWA to CareOregon within three (3) days of discovery.

If you are interested in becoming a contracted provider, please review our credentialing requirements to ensure you meet the qualifications. Credentialing requirements are outlined in our provider manuals:

• Health Share/CareOregon Behavioral Health providers
• All other CareOregon Behavioral & Physical Health providers

If you meet credentialing requirements and would like to be considered for a contract or have additional questions, please complete the Contract Requests form here. CareOregon is committed to improving health equity by reducing health disparities historically associated with characteristics commonly linked to discrimination or exclusion.

• Information about the provider’s race, ethnicity, and cultural linguistic capabilities. 
• The availability of auxiliary aids and services for all members with disabilities, upon request .
• Whether providers have verifiable language fluency in languages other than English.

CareOregon helps you coordinate interpreters for patients who prefer or need a language other than English. Please visit our Language services page for resources, including forms to request interpreting services, a language ID tool for your facility, “I speak” cards, and more.

Health-related services (HRS) are CCO-optional services offered as a supplement to OHP-covered benefits. They are intended to help improve care delivery and overall member/community health and well-being. To learn more about HRS, visit our health-related services web page.

CareOregon Regional Care Teams (RCTs) offer providers a community of resources with a single point of contact for you and your patients. To learn more about these resources, visit our Care Coordination services page.

CareOregon invests to support our complex care ecosystem and improve outcomes for our members through our Regional Care Team and different CareOregon sponsored complex care programs. Download a pdf below to learn more about these complex care programs:

• Housecall Providers Advanced Illness Care (AIC) Team
• Bridges to Change
• CCC Recuperative Care Program
• OHSU Transitional Care Team
• PFR CHAT Program
• Summit AICU Flyer
• Quest WISH Program

When submitting claims to CareOregon, you have two options:

• Send claims electronically using our payer ID 93975.
• Mail paper claims to:
  • Claims, CareOregon
    PO Box 40328
    Portland OR 97240

To submit claims electronically:

• Use the same EDI Payer ID #93975 for all CareOregon entities (CareOregon Dental, CareOregon Advantage and CareOregon Medicaid claims). Do not bill separately for each plan.
• For EDI claims for which additional paperwork or documentation will be submitted, complete this form and indicate submission in the PWK segment (Loop 2300). 
• Contact your practice management system vendor or clearinghouse to initiate electronic claim submission. CareOregon accepts HIPAA-compliant 837 electronic claims through our clearinghouse, Change Healthcare. Change Healthcare will validate the claims for HIPAA compliance and send them directly to CareOregon. Change Healthcare offers several solutions for providers without a practice management system or clearinghouse. Contact them at 866-369-8805 for medical claims and 888-255-7293 for dental claims.

The AMA recognizes electronic health care transactions as a cost saving, efficient way to do business and allows physicians to refocus resources on patient care. The links below provide information regarding various electronic transactions such as submitting claims, receiving payments and remittance advices.

To access your remittance advice electronically:

• Remittance advice FAQ

To receive payments via Electronic Funds Transfer (EFT):

CareOregon provides a couple of options for electronic payment.

1. Enroll with CareOregon ePayment Center, administered by Zelis for ACH direct deposit payment, at no cost. Please contact the ePayment Center customer service team at 855-774-4392 or help@epayment.center for instructions on how to register and enroll. Please note, TIN verification is required for registration and enrollment.
   • EFT and ERA Online FAQs
2. Enroll with Zelis Payment Network for ACH direct deposit payment or virtual credit card for a small fee (this is separate from CareOregon’s free ePayment ACH option noted above). To enroll with the Zelis Payment Network, go to their website at https://www.zelis.com/providers/provider-enrollment/, or you can call them at 855-496-1571.
   • Please note: CareOregon is not involved in any relationship with providers and Zelis Payments. It is strictly between Zelis and you, the provider.

To receive electronic remittance advice:

• 835 form: Please complete and fax back to the number listed on the bottom of the form
• 835 information guide
  • Important: 835 enrollment is available through CareOregon ePayment Center, administered by Zelis. If enrolling with the ePayment center, please do not submit this form. Instead, select the option for 835 enrollment upon registration through the ePayment center.

• 2021 Evaluation & Management Coding guide
• Claim adjustment reason codes
• Remittance advice remarks codes

• Portal (24/7 access) for claims, authorizations, remittance, etc.
  • CIM
  • CONNECT
  • OneHealthPort
• Call Customer Service 800-224-4840, option 3 
• Send us a secure email for larger inquiries at claimshelp@careoregon.org 

• Acupuncture guide
• Continuous Glucose Monitors and Supplies guide
• Ketamine Spravato for Mental Health guide
• Modifier 25 guide
• Telehealth guide
• CLIA QW guide
• Prolonged services coding guide
• 90899 billing and coding guide
• Billing for Bilateral Services Guide
• Comanagement of Surgical Care use of Modifiers 54, 55 and 56
• Limited Coverage for Major Surgeries in a non-facility setting
• Global Period for Minor and Major Surgeries
• Clinical Trials Studies Registry Claims
• Emergency Department Outpatient Facility Evaluation and Management Coding Policies
• Provider-administered drug pricing guide
• COVID-19 vaccine guide
• Sepsis coding guide

Training

This training is required for all participating provider groups. CareOregon’s FWA training fulfills both Medicaid and Medicare requirements.

Frequently Asked Questions (FWA 2025)

Please review the two items below and complete an attestation.

• CareOregon OHP Fraud, Waste, Abuse Provider Training
• CareOregon Fraud, Waste, Abuse Handbook
  • Required by Coordinated Care Organization contract with the Oregon Health Authority (Exhibit B, Part 9, Section 11)
• Once the training is completed, please fill out the attestation here: FWA Attestation 2025

Note: If there is an alternative training completed that includes Oregon Medicaid requirements, providers will still need to review the reporting process in the training document (page 26), CareOregon’s Code of Conduct (located in the handbook on page 49), and complete an attestation.

• Special Needs Plan Model of Care Training – Provider Module
• If you have questions, please contact:
  

  Andrew Missel

  PHP Quality Manager

  missela@careoregon.org

• Please complete and submit the following Model of Care Clinic/Practice Attestation once you’ve completed the training.

2022 CareOregon Quality Metrics Toolkit - all measures

Coding Guidelines

• Risk Adjustment Coding Guidelines

Coding Tips

• Coding and Documentation Tips: Diabetes with other specified conditions
• Coding and Documentation Tips: Diabetes with conditions
• Coding and Documentation Tips: Diabetes Uncontrolled
• Coding and Documentation Tips: Morbid Obesity and Body Mass Index
• Coding and Documentation Tips: Pressure Ulcer Staging
• Coding and Documentation Tips: History of
• Coding and Documentation Tips: Acute vs Chronic Conditions
• Coding and Documentation Tips: Amputations
• Coding and Documentation Tips: Ostomies
• Coding and Documentation Tips: Telehealth
  
• Coding Issues and Tips
• Coding Tip Sheet for Borderline Diagnosis
• Hierarchical Conditions Categories (HCCs) - an Introduction

Stay connected to the OHP with various resources available to Oregon’s Medicaid providers.

• MMIS (OHP provider web portal)
• OHP web portal training
• Sign up for OHP updates

For information on how to establish the 270/271 real time batch eligibility verification process, please contact us at (800) 224-4840 or providercustomerservice@careoregon.org after reviewing these initial prerequisites: 

• Must be a CareOregon Participating/Contracted Provider
• Must have ability to establish an SFTP Connection: Have FTP solution and provide an SFTP Technical Contact

 What Has Changed? 

• Effective 1/1/2024 Licensed Professional Counselors (LPC) and Licensed Marriage and Family Therapists (LMFT) are able to bill Medicare Part B and be reimbursed for approved services in accordance with Medicare reimbursement rates. 
• This change is due to the passage of the Mental Health Access Improvement Act by Congress in December of 2022 (S.828/H.R.432). 
• This federal law is closing a gap which has historically prevented LPCs and LMFTs from being recognized as Medicare providers. 

 How to Enroll as a Medicare Provider? 

• As of November 2023, LPCs and LMFTs are now eligible to enroll as a Medicare billable provider through the Center for Medicaid and Medicare Services (CMS).
  • NOTE: CMS sometimes refers to LPCs as Mental Health Counselors. 
    
• If you are currently a Medicaid provider, the following is required:
  • Complete the Medicare Enrollment Application through PECOS – may take 60-90 days. 
  • Once enrolled, inform CareOregon by emailing a copy of the PTAN letter to BHproviderdataupdates@careoregon.org 
    
• IMPORTANT! Providers who have officially opted out of Medicare are not eligible to receive payments for dual-eligible members. 

Need Additional Support with Enrollment? 

• Medicare Administrative Contractors (MAC) are available per regional assignment to support providers with enrollment needs. 
• Oregon providers can find more information on this support through Noridian: Provider Enrollment (JF Part B) 

To support this transition & member access, please note the following: 

• We do not require a primary Medicare EOB for LPCs and LMFTs for dates of services billed between 1/1/24 and 6/30/24. 
• Once Medicare enrollment is complete, notify CareOregon by emailing a copy of the PTAN letter to BHProviderDataUpdates@careoregon.org so provider records can be updated. 
• Claims paid under the CareOregon Medicare Advantage (COA) plan will automatically crossover to the CCO plan. 
• If a member has external Medicare, providers must bill Medicare first. 
  • Fee-for-service, or Traditional Medicare, will send CareOregon a crossover claim – no need to bill CareOregon separately. 
  • For other Medicare Advantage Plans, include primary payer's payment info on the claim. Secondary claims should be billed electronically, whenever possible. 
    
• Medicare rates may be lower than CareOregon rates. To reduce burden on our providers & ensure continued access for our dually enrolled members, we are reviewing our COB calculation method with plans to reimburse providers at least up to the Medicaid rate in the future when totaling payments for primary & secondary payers. 

Helpful Resources

• Online Medicare Enrollment Application 
• Paper Medicare Enrollment Application 
• September 2023 FAQ Document (CMS website) 
• How to become a Medicare provider (CMS website) 

As of December 9, 2024, CareOregon is using a new vendor, IC System, to collect outstanding debt/overpayment from providers. Below is a description of the process.

Phase 1 - For balances of $50 or more
IC System will send a letter to the provider’s physical address. If after 30 days the attempt to collect is not successful, IC System will send out a second letter. After an additional 30 days from the date of the second letter, if there continues to be no response from the provider, IC System will call the provider to confirm contact information.

Phase 2 - For balances of $200 or more
The collection process will automatically begin in Phase 2. Once an outstanding balance has been moved to Phase 2, all inquiries and correspondence will need to be made with IC System directly. Your PRS contact will not be able to discuss balances that have been transferred to Phase 2 with IC System.

Contact information for IC System Client Services Department

Phone: 800-685-0595

Email: clientservice@icsystem.com