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Eligibility verification

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... the date the client's coverage ended or the 'To DOS' you listed in your request. ... 1. This example shows a 'From/To DOS' date range. ... – PowerPoint PPT presentation

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Title: Eligibility verification


1
Eligibility verification
  • Department of Human Services
  • December 2008

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
Resources
  • To verify client medical eligibility, there are 2
    options to choose from, they are
  • Automated Voice Response (AVR).
  • MMIS Provider Web portal.

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
Medical care identification
  • The medical care
    identification card will

    only provide
  • Client name
  • Client number
  • Date the card was issued

6
Automated Voice Response (AVR)
7
What is AVR?
  • The automated voice response (AVR) is a computer
    system that gives
  • Client eligibility
  • 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
What does AVR provide?
  • The AVR can tell you the following information
  • A clients Medicaid ID number
  • A clients date of birth
  • If a client is eligible on a specific date of
    service
  • Which benefit plan the client is eligible for
  • The clients copayment requirements
  • If a service is covered in the clients benefit
    plan
  • If the client is enrolled in a managed care plan
  • If the client has other insurance coverage
  • The date of the clients last vision exam and
    dispensing

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
  • 800-336-6016
  • DMAP.providerservices_at_state.or.us
  • Monday - Friday, 800 a.m. to 500 p.m.

10
(No Transcript)
11
Provider Web Portal
12
Provider Web portal
  • Providers can use the Web portal to
  • Verify client eligibility and perform clerk
    maintenance
  • Future functions
  • 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
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
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
Web Portal login
  • 1. Select Account.
  • 2. Select Secure Site.
  • Enter your user name and password.
  • Select login.

16
Home page
  • Select Eligibility.

This is the DHS provider that corresponds with
the user name entered on the previous screen.
Provider ID MD Taxonomy Zip
Code -
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
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 todays date.
  • The Provider Web portal will not give future
    eligibility information. All end dates listed in
    your search results are either the date the
    clients coverage ended or the To DOS you
    listed in your request.

XXX
11/30/2008 11/30/2008
19
Eligibility search results displays 6 sections
XX X
12/09/2000
5503 (503) 378-2666
DOE JANE A
  • 1. Client information
  • 2. Benefit Plan (formerly benefit package)
  • TPL (third party liability)
  • Managed Care
  • Lockin
  • Service Limitations

20
Client information section
  • The client information section displays basic
    information about the client.

X X X
12/09/2000
5503 (503) 378-2666
DOE JANE A
21
Benefit plan section
  • The benefit plan section gives information about
    the clients benefit plan.
  • The following codes indicate DHS benefit plans
    (formerly benefit packages). Disregard all other
    codes they are for internal use only.

Benefit Plan Effective Date
End Date



BMH 04/15/2008
11/30/2008



CRN 04/15/2008
11/30/2008



SMHS 04/15/2008
11/30/2008
BMD OHP with Limited Drug BMH OHP Plus
KIT OHP Standard MED
Qualified Medicare Beneficiary (QMB)
BMM QMB OHP with Limited Drug
CWM Citizen/Alien-Waived
Emergency Medical (CAWEM)
CWX CAWEM Plus
22
Third party liability (TPL) section
Carrier Name Policy Number
Policy Holder Coverage Type
Effective Date End
Date Blue Cross
Doe, John
Major Medical 08/01/2000
11/30/2008
Prime Dental
Health
Doe, John Dental
08/01/2000
11/30/2008
  • Displays specific information about the clients
    third-party resources (other insurance).

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

Provider Name Provider
Phone Plan Type
Effective Date End Date Care Oregon Inc
(503) -
FCHP 11/17/2008
11/30/2008
Mid-Valley
Behavioral Care (503) -
MHO 11/10/2008
11/30/2008
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.

Lockin Plan Effective Date
End Date Provider
Provider Name Provider
Phone Pharmacy
08/01/2000 10/31/2007
NPI My Pharmacy
(503) -
25
Service limitation section
  • This section shows the next available date for a
    specific service that has limitations according
    to Oregon Administrative Rules.

Service Limitation has been found for Procedure
Code 92002, next possible date of service is
12/01/2008
26
Open card example
  • 1. This example shows a From/To DOS date
    range.
  • 2. Indicates that the client has Medicare Parts
    A, B and D coverage.
  • 3. Indicates the client is in the Qualified
    Medicare Beneficiary benefit plan.
  • No rows found indicates the client does not
    have any other insurance coverage and is not
    enrolled in a managed care plan during the
    From/To DOS listed in this request.

27
Managed care example
  • 1. This example shows a From/To DOS date
    range.
  • 2. Indicates that the client does not have
    Medicare coverage.
  • 3. Indicates the client is in the OHP Plus
    benefit plan.
  • Indicates the client is enrolled in Care
    Oregon (medical plan) beginning 11/17/2008, and
    Willamette Dental (dental plan) beginning
    11/10/2008.

28
Client not eligible example
  • 1. This example shows a specific From/To
    DOS date range.
  • Indicates that the subscriber (client) is not
    eligible for the requested From/To DOS date
    range.

29
Logging off
  • Be sure to logoff when you are done.
  • 1. Click Account from the menu bar.
  • 2. Click Logoff.

30
Logoff notify
  • Once logged off, the following message will
    display.

31
Contact
  • If you need assistance determining client
    eligibility, or other information accessing the
    Provider Web portal, contact
  • DMAP Provider Services
  • 800-336-6016
  • DMAP.providerservices_at_state.or.us
  • Monday - Friday, 800 a.m. to 500 p.m.

32
Thank you!
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