Provider Enrollment and Claims Submission Requirements
- Enrollment: To receive payment for services provided to an Umpqua Health member, the provider or facility must be enrolled with the State of Oregon and have an active DMAP number on the date(s) of service.
- Claims Submission: UHA accepts paper and electronic claims in HIPAA 837P, 837I, CMS-1500, or UB-04 formats. Claims are typically processed within 60 days of receipt of a clean claim. Non-clean claims typically result in a longer adjudication timeline.
- Denials: If you received a claim rejection letter from Ayin Health Solutions, please contact them directly at (503) 584-2169, option #5. Umpqua Health does not have access to those claims and Ayin Health Solutions will advise on possible solutions.
Out-of-Area Providers
If you are an out-of-area provider seeking enrollment with DMAP, please review our Guide for Submitting Provider Enrollment Requests. Ensure you meet all enrollment requirements as outlined in Oregon Administrative Rules OAR 410-120-1260 and OAR 407-120-0320.
Electronic Claim Submission (EDI)
- UHA accepts HIPAA-compliant 837P and 837I electronic claims.
- Electronic Data Interchange (EDI) offers a faster and more cost-efficient alternative to paper claim submissions.
- The online submission system performs a preliminary review of each claim to identify and flag common billing errors prior to acceptance.
- Please note that most requirements for paper claims also apply to EDI submissions.
For comprehensive guidelines on 837P and 837I transactions, please refer to the CMS website.
Payor IDs
Select the correct payor ID numbers based on your organization’s clearinghouse.
| Clearinghouse | PAYOR ID |
| Allscripts/PayerPath (via forwarding) | 77502 |
| Availity | 77503 |
| Cortex EDI | CIM11 |
| ClaimMD | 77501 |
| GE Healthcare/Athena | 77500 |
| Gateway/Trizetto | 77504 |
| Office Ally | 77501 |
| Relay Health PCS (Professional) | 77505-CPID 1291 |
| Relay Health PCS (Institutional) | 77505-CPID 6551 |
Paper Claim Submission
- OHA adheres to Medicare and OHA guidelines for processing of paper claims.
- Submit claims on the current CMS-1500 or UB-04 forms.
- Please see the UHA Provider Handbook for additional information.
Paper Claims Submission Address:
Ayin Health Solutions
Attn: UHA Claims
PO Box 5308
Salem, OR 97304
Claim Appeals Address:
Ayin Health Solutions
Attn: UHA Appeals
PO Box 5308
Salem, OR 97304
Elements of a Clean Claim
A clean claim has no defect, impropriety, or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claim forms, along with any attachments and additional elements, or revisions to data elements, attachments, and additional elements, of which the provider has knowledge.
UHA will apply the National Correct Coding Initiative to claims processed as required in Section 6507 of the Patient Protection Affordable Care act.
Some of the required data elements for professional and facility claims.
- Member ID #
- Member’s Name
- Members’ date of birth and gender
- Prior Authorization
- Diagnosis code(s)
- Date of service
- Place of service
- Bill Type
- Procedure/ modifier code
- Dx pointer
- Charge for each listed service
- Number of units
- Rendering provider NPI
- Tax ID number
- Total charges
Timely Filing Guidelines
- Original Claims: Must be submitted within 120 days from the date of service (or discharge date for inpatient stays).
- Corrections, Appeals, and Secondary/Tertiary Billing: Must be submitted within 365 days from the date of service and must include the primary EOB/documentation.
- The following data elements are used to identify duplicate /corrected claims.
- Place of service
- Units billed
- Charges
- Rev Code
- Benefit Plan (CCOA, CCOB, CCOG, CCOE, CCOF)
- Diagnosis code
- Bill type
- NDC Modifiers
- When one of these elements is identified in our claims system, the claim will pend for manual processing. Corrected claims should be referenced as a corrected claim on the claim form along with the original claim number. Partial corrections on a claim will be denied as a duplicate. The whole claim needs to be rebilled under the corrected claim.
- The following data elements are used to identify duplicate /corrected claims.
- Providers are encouraged to submit within 30 days of the date of service to facilitate the collection of encounter data and provide effective utilization management.
If you encounter system issues or other delays affecting timely billing, UHA must be notified immediately using the Contact Us information below.
Timely Filing Appeals
Appeals must be attached to the claim. Acceptable proof of timely filing includes:
- RA/EOB, or
- A screenshot or system-generated transaction history showing the claim submission date (within timely limits), along with at least three of the following:
- Member ID
- Member name
- Procedure code
- Billed charges
- Date of service
Note: Delays due to DMAP enrollment are not considered valid reasons for untimely claim submission. Once enrollment is complete, claims are automatically reprocessed; however, the original submission must fall within the timely filing guidelines.
Please see the Umpqua Provider Handbook, Section 6: Filing Claims for more detailed information.
Claim Reconsiderations & 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.
Other Notices
To be compliant with Oregon Administrative Rule 410-130-0180, Umpqua Health requires all providers to report the National Drug Codes (NDCs) on claims submitted. This is for all physician-administered drugs billed using a Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT®) code. NDC coding applies to claims for services billed on:
- CMS-1500 for providers
- UB-04 for hospitals and facilities
- Electronic data interchange (EDI) 837
What NDC information should be included on claims?
Claims should include the following information:
- Valid 11-digit NDC number
- NDC Unit of Measurement (UOM)
- NDC units dispensed/administered (must be greater than 0)
Learn more about formatting NDC claims. You can also review our NDC Validation Process diagram.
Where is the NDC located?
The NDC is usually found on the drug label or medication’s outer packaging. If the medication comes in a box with multiple vials, using the NDC on the box (outer packaging) is recommended. The number on the packaging may be less than 11 digits. An asterisk may appear as a placeholder for any leading zeros. The container label also displays information for the unit of measure for that drug. Listed below are the NDC units of measure Umpqua Health covers with examples:
- UN (Unit) – Powder-filled vials for injection (needs to be reconstituted), pellet, kit, patch, tablet, device.
- ML (Milliliter) – Liquid, solution, or suspension.
- GR (Gram) – Ointments, creams, inhalers, or bulk powder in a jar.
- F2 (International Unit) – Products described as IU/vial, or micrograms.
Note: ME is also a recognized billing qualifier that may be used to identify milligrams as the NDC unit of measure; however, drug costs are generally created at the UN or ML level. If a drug product is billed using milligrams, it is recommended that the milligrams be billed in an equivalent decimal format of grams.
How to verify the NDC is valid?
To most closely align with OHA’s NDC requirements, Umpqua Health uses the CMS Durable Medical Equipment (DME) Pricing Data Analysis and Coding (PDAC) NDC Cross-walk file and the Food and Drug Administration (FDA) NDC Database file. In combination, these files contain the NDC’s that are valid.
Need more information?
If you have questions about NDC billing that are not listed here, please email our Claims Department at UHAClaims@umpquahealth.com.
The Vaccines for Children (VFC) Program is a federal program that provides free immunizations for children age 0–18 years. Umpqua Health does not reimburse for the cost of vaccine serums covered by the VFC Program. Providers should bill Umpqua Health only for the administration of the vaccines covered under the VFC Program.
Providers should bill the specific immunization CPT code with modifier 26 or SL, which indicates administration only. Providers should not bill for the administration of these vaccines.
Providers not participating in the VFC Program should refer their patients to the County Health Department to receive the vaccines covered under the program. We do not require an invoice to be submitted with the claim for providers who are not enrolled in the VFC program.
Sterilization consent forms are required for payment on any claim billed with a sterilization procedure code. We are required to submit the consent forms to OHA for any sterilization charge received. If we are unable to obtain valid consent, the claim will be denied and or recouped. This applies to professional, and facility claims.
Tips for complete consent forms:
- The patient must sign the consent form at least 30 days, but no more than 180 days prior to the procedure.
- Any interpreter’s statement must be signed and dated the same day as the member/patient signs the consent form.
- The physician’s statement must be filled out completely, and the physician’s signature must be dated on the date of the procedure.
- The statement of the person obtaining consent must be signed and dated on the same date as the member.
Consent forms can be found here.
Providers are prohibited from billing an Umpqua Health member for Medicaid-covered services. Members may only be billed if all the following criteria are met:
- The service is not covered by Medicaid.
- All reasonably covered treatments have been tried OR member is aware of reasonably covered treatments but selected a treatment that is not covered; and
- Member and provider have completed an OHP Client Agreement to Pay for Health Services (OHP 3165)
These coverage rules are outlined in OAR 410-120-1280.
Contact Us
UHA Claim Support Team (available Mon-Fri, 8am –5pm PST)
