This piece covers organizational enrollment with OHA's fee-for-service program (open card) and how it connects to coordinated care organization contracting. It is general information, not legal advice.
Your license or certificate comes first
OAR 410-172-0610 requires behavioral health providers to be enrolled with the Health Systems Division as a behavioral health provider and to hold a current, valid license, letter, or certificate. It also pulls in the general enrollment rule, OAR 410-120-1260, and bars anyone on a federal Office of Inspector General exclusion list.
Under OAR 410-120-1260, the license must be active, and OHA may deny enrollment if the licensing body has placed limitations on it. The provider type you enroll under also has to be one the State Plan approves for Medicaid reimbursement.
For programs certified under OAR chapter 309, division 8, the letter that comes with the certificate spells out the scope and the approved service delivery locations. If a site or service isn't on that letter, resolve it with OHA licensing before you list it on a Medicaid application.
The organizational packet
According to OHA's OHP Provider Enrollment page, organizations enroll with three forms:
- OHA 3972, the payable provider enrollment form
- OHA 3974, the disclosure statement of ownership and control
- OHA 3975, the provider enrollment agreement
Some provider types and specialties need an additional attachment, and the page lets you search by provider type to check. OHA prefers online submission through the MMIS Provider Portal. Fax is the fallback, and a faxed packet has to sit under an EDMS coversheet with the Provider Enrollment box checked. OHA accepts an older version of a form for only three months after a revision, so download fresh copies.
Before you apply, the organization needs its own NPI and taxonomy code from NPPES. OAR 410-120-1260 requires both on the application, and the enrollment is tied to that specific NPI. You will also need your OHA provider type and specialty codes, which OHA publishes in a list linked from the same page. After you submit, the Application Tracking Number lets you check status online.
Disclosure is where packets stall
OAR 410-120-1260 requires the organization to disclose its name, tax ID, primary business address, every business location, and every P.O. box. It also requires the name, tax ID, and date of birth of each person with a direct or indirect ownership or control interest, each agent, and each managing employee. Owners must disclose family relationships with other owners and any other current or former Medicaid providers they hold an interest in, plus any subcontractor in which the organization owns 5 percent or more.
The penalty for gaps is specific. OHA may not pay for services furnished from the day after the information was due until the day before it arrives, and it will suspend or terminate the enrollment under federal disclosure rules.
Before anyone opens the portal, put together an ownership chart with percentages and a list of managing employees. For a treatment program, that list usually includes the program director and clinical director. Collect their identifiers through a secure channel instead of email.
Screening, site visits, and fees
Federal rules sort Medicaid applicants into limited, moderate, or high categorical risk. Under 42 CFR 455.450, every applicant gets license verification and database checks. Moderate and high risk applicants also get site visits under 42 CFR 455.432, which the state must conduct before and after enrollment. High risk adds a criminal background check and fingerprints, which under 42 CFR 455.434 reach anyone with a 5 percent or greater ownership interest. OAR 410-120-1260 adds that OHA, CMS, and their contractors may make unannounced inspections of any provider location.
Organizations may also owe a federal application fee. Under 42 CFR 455.460, the state collects it before executing the provider agreement. The fee doesn't apply to individual physicians and nonphysician practitioners, or to providers already enrolled in Medicare or another state's Medicaid program, or that have paid the fee to a Medicare contractor or another state.
Apply from a finished site whose address matches the certificate, with staff on hand who can answer questions about the program.
Clinicians enroll too
Individual clinicians whose services the organization bills enroll as non-payable providers. OHA's page notes that this covers rendering, ordering, prescribing, and referring providers, and that prescribers must be enrolled with Oregon Medicaid for their prescriptions to be covered.
Three details in OAR 410-120-1260 trip up new groups. The billing NPI and the rendering NPI can't be the same on a claim. Before the organization submits claims for a clinician, it needs that clinician's signed authorization to bill and receive payment on their behalf, kept for at least seven years. And a provider with a second NPI needs a separate enrollment, approved before that NPI appears on a claim.
Where CCOs fit
OHA notes that CCOs serve over 90 percent of OHP members, and it directs CCO enrollment and credentialing questions to each CCO. Fee-for-service enrollment and CCO contracting are separate tracks, so run them in parallel.
OAR 410-141-3510 governs CCO credentialing. Plans must credential participating providers at initial contract, recredential within three years, accept the Oregon Practitioner Credentialing Application, and screen providers under the same federal rules in 42 CFR 455 Subpart E. CCOs must also require atypical providers to be enrolled with OHA, and OAR 410-120-1260 lets a CCO-credentialed provider enroll with OHA as an encounter-only provider.
The same rule says a CCO may not discriminate against a provider acting within the scope of their license or certification on the basis of that license. It also says a CCO doesn't have to contract with every willing provider. If a CCO declines you, it must give the reason in writing, and you can use its internal review process and then appeal to OHA.
After approval
The enrollment agreement expires five years from enrollment, and OHA revalidates at least that often. Missing a revalidation request ends the enrollment. Material changes, including a new tax ID, location, ownership, NPI, or a criminal conviction, must be reported in writing within 35 calendar days under OAR 410-120-1260, and OHA's enrollment page asks for updates within 30 days. Use the 30-day number. Under 42 CFR 455.450, an application for a new practice location is screened like an initial application.
The OHA 3972 instructions add that OHA may deactivate providers with no claim activity in an 18-month period.
A short checklist
- Confirm that the certificate letter lists every site and service you plan to bill.
- Get the organization's NPI and taxonomy, and look up your OHA provider type and specialty codes.
- Build the ownership and managing employee disclosure before starting the OHA 3974.
- Download current versions of the forms and submit through the MMIS Provider Portal.
- Have the site ready for a visit on the day you submit.
- Enroll each clinician as non-payable and collect signed billing authorizations.
- Start CCO contracting and credentialing in parallel, with your OHA enrollment details on hand.
- Calendar revalidation and assign one person to report changes within 30 days.
Saint Health Group helps Oregon behavioral health programs with credentialing and Medicaid enrollment as they open or add sites.
Sources
- Oregon Secretary of State, OAR 410-120-1260, Provider Enrollment
- Oregon Secretary of State, OAR 410-172-0610, Provider Enrollment (Medicaid Payment for Behavioral Health Services)
- Oregon Secretary of State, OAR 410-141-3510, Provider Contracting and Credentialing
- Oregon Secretary of State, OAR 309-008-0200, Definitions (Certification of Behavioral Health Treatment Services)
- Oregon Health Authority, OHP Provider Enrollment
- eCFR, 42 CFR 455.450, Screening levels for Medicaid providers
- eCFR, 42 CFR 455.432, Site visits
- eCFR, 42 CFR 455.434, Criminal background checks
- eCFR, 42 CFR 455.460, Application fee
Easton Hallock is Managing Partner at Saint Health Group, which works with behavioral health and substance use disorder programs on licensing, credentialing, payer contracting, and billing.
