CLAIMS

Access

Umpqua Health Alliance offers providers the ability to submit, check the status and manage your prior authorization (PA) requests online. By signing up for access to our Community Integration Manager (CIM), you can eliminate paperwork and faxing associated with the authorization process. You will also have direct email access to our Member Services, Prior Authorization, and Claims teams that can assist you with questions of member eligibility, and monitoring PA and claims status’. UHA is encouraging all in network providers to gain access to CIM as soon as possible as it will be a requirement in the first quarter of 2020.

Claims Submissions

UHA accepts paper and electronic claim submissions and these should be submitted in HIPAA 837P, 837I, CMS 1500, or UB-04 format. In order to be paid for services rendered to a UHA member, provider and or/facility MUST be enrolled with the state of Oregon and have an active DMAP number for the date(s) of service. If you are an out of network provider needing to be enrolled with DMAP, please contact Provider Services by phone at (541) 229-7077 or by email UHNProviderservices@umpquahealth.com.

Claims are typically processed within 60 days of receipt of a clean claim. Non-clean claims typically result in a longer adjudication window and/or denials. If you received a claim rejection letter from PH Tech, please contact them directly at (503) 584-2169, option #5. UHA does not have access to those claims and PH Tech will advise on possible solutions.

Claim Submission Methods

UHA has a claim support team available by phone Monday-Friday 8 a.m.-5p.m. PST at (541) 229-4842 option 2 or can be reached by email at UHAClaims@umpquahealth.com. If sending any PHI through email, please ensure that it is sent via secure email.

Timely Filing Guidelines

• 120 days from the date of service for original submissions (unless it is an inpatient stay, then date of discharge).
• 1 year (365 days) from date of service for corrections, appeals, and secondary/tertiary billing (primary EOB/documentation must be included with original claim submission).
  • If you are experiencing any system issues with claim submissions or any instances that will delay timely billing, UHA MUST be notified as soon as issue is identified via contact information below.

Please note that DMAP enrollment is not a valid reason for untimely claims submission. Once provider/facility becomes enrolled claims are automatically reprocessed and original submission must be within the timely guidelines above.

Claim Reconsiderations and Provider Appeals

If you have received a claim denial/payment that you do not agree with, you may contact UHA’s claim support team. This is considered a Reconsideration (Level I Appeal) once the claims support team takes a second look at the denial/payment. If the UHA claims support team does not find any issue with the processing of the claim, you may also submit a written Claims Appeal (Level II Appeal). You must include the Provider Request for Reconsideration and Claim Dispute Form found below, and all documentation you feel is necessary for UHA to reconsider the claim denial. You can either mail the appeal, or submit through CIM directly on the claim. Please see How to Upload Additional Documentation for instructions. If you need more information on this process, see the UHA Provider Handbook; Section 6.11 Denials and Claim Appeals.

Please Mail Paper Appeals to:

***Please note address must match as listed or claim may be rejected***
PhTech
ATTN UHA Claims Appeals
PO BOX 5308
Salem, OR 97304

Forms

• Provider Request for Reconsideration and Claim Dispute Form
• OHA Waiver of Liability Form

Additional Resources

• OHA Billing Basics
• National Drug Code Requirements
• Tools for OHP Providers (quick tips and guides)
• 2020 Coordinated Care Organizations for Providers
• Provider Handbook
• Oregon Health Plan Providers
• DMAP Fee Schedule Page
• Prioritized List
• OHA Request for Claim or Payment Authorization Review
• OHA VFC Program Resources

Contact Us

• For DMAP enrollment/inquiries, contracting, or provider network questions
  • Contact Provider Relations at (541) 957-3094 or UHNProviderServices@umpquahealth.com
• For general claim support including denials and payment questions
  • Contact UHA Claims Support Team at (541) 229-4842 option 2 or via secure email to UHAClaims@umpquahealth.com
• For EDI, direct claim submission, or CIM issues
  • Contact PhTech EDI Support at (503) 584-2169 or support@phtech.com
• To report third party liability, secondary payment questions, or TPR refund requests
  • Contact TPR at (541) 464-4175 or UHTPR@umpquahealth.com
• For prior authorization questions
  • Contact Prior Authorizations by email at priorauthorizations@umpquahealth.com