Description: This article is mainly focused on verification on the Oregon Medicaid provider web portal where you would verify eligibility for oregon health plan enrollment.
Verification on the Oregon Medicaid provider web portal, so this is where you would verify eligibility for oregon health plan enrollment. So I’m logged into the provider web portal here and what I’m going to do is to click on the eligibility menu, here’s my eligibility verification request screen, this is where I enter information about a person to see if they are a current client on the Oregon Health Plan.
So you have to enter a combination of information on this request screen, and then click on the search button to find that person. So if you are not sure what you need to enter, or you have the right combination of information to pull up, leave everything blank, and you can click on the search button, the system is going to tell you what it needs to find a person in the system, you will see there are different combinations to find this specific client.
And then you need from a date of service and a to date of service, so I’m going to go ahead with a client ID and birthdate. The date of service can be one day, it can be the same date, but it cannot be any later than the current date. So it has to be through today or before, but it can be also a date range, your date range can be up to 13 months in length as long as you don’t try and look at a future date you should be good with that.
Sometimes when you have multiple dates, you have to pay a little closer attention, because sometimes the plans change or third-party liability may drop off for a couple of days. There may be lapses and coverage, so always make sure that you’re looking at your date’s very closely on the eligibility file when you search for a date range. The top section is basic client information, if the client has Medicare coverage, you would see effective and end dates under the appropriate type of coverage.
The benefit plan is where you’ll see the enrollment for that client, you also see contract nursing and mental health services plans, and then there’s that effective and end date. If there has been a lapse in coverage, it is possible that one of these dates would be different than what you searched for.
The next section is service types coverage and copay, this is where you can see what service types are covered according to a specific benefit plan that a person has. And whether or not, they have a cold case or those services. Now what you’ll do is to click on their basic benefit plan, and then you’ll see those service types and whether or not there’s active coverage, you can see dental care, and then whether or not there’s a copay.
You can look in the rules for that specific service, and it’s even in the general rule book of the Oregon administrative rules to find out what those limitations are. So there are dental and vision limitations for non-pregnant adults, so that’s why you’re seeing limitations there. TPL stands for third-party liability, every person has private insurance, so if the person has private insurance and has been reported to their caseworker, we’re aware of it here at Oregon Health Plan.
Next is managed care, so under managed care, you are going to see coordinated care organization. If a client is enrolled in it, it means that this client is enrolled in a specific plan that handles prior authorization and billing for this client, so they basically manage the care for this client, so you’ll see this person is enrolled in Willamette Valley Community Health.
And then what you’ll see is that provider phone number, in case you need to reach them, you’ll see the plan and end date of that enrollment again, pay attention to those days because it is possible that may be researched for the entire month. But it’s possible that they were not enrolled in that organization for that entire time, so make sure you pay attention to those dates.
Next we have walk-in and if a client is locked into a specific pharmacy, and you’ll see that pharmacy information there and then our last section on the eligibility file of service limitations is when you’re doing your search on the panel at the top, you enter a procedure codes, there is a field where you can enter a procedure code up there. And if you do that, before you click on search, the service limitations section is going to tell you whether or not there are limitations for that specific procedure.
Let’s go to see the TPL, you’ll see a lot of the information looks the same, but then what you’ll see is if we get right down here to the TPL, section third-party liability, you can see that this person has medical coverage through another carrier. So right here, you’ll see BCBS of Oregon, that’s blue cross, blue shield of Oregon. you’ll see a policy number, the policyholder, the type of coverage.
This is major medical, including maternity and then you’ll see effective and end dates within the range, the only other thing I’m going to point out on this eligibility file is that this plan type of the third party liability under the managed care is different.
We do have some areas that are not completely up with coordinated care organizations yet, so sometimes you might see a different type of plan. One other file I do want to show you is the lock-in. If you look at the benefit plan section, you can see the current status of the client, pregnant or not, if you click on the plan, you will see the other active plans for the member.
So here this plan is locked into a specific pharmacy, and you’ll be able to see that information here, they have the effective and end date within your date range. And then you’ll see the provider name, and usually you’ll see a valid provider phone number there as well.
So that’s how you can see locked in and that is eligibility on the Oregon Medicaid provider.