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The Oregon Health Plan coordinates Medicaid through 16 regional CCOs operating under global budgets. Each CCO—such as Health Share of Oregon, PacificSource, AllCare, and Trillium—maintains distinct network credentialing, formulary requirements, and prior authorization rules. Submitting claims to the wrong regional CCO results in prompt rejections.
Regence BlueCross BlueShield of Oregon and Moda Health hold dominant commercial market share, alongside Kaiser Permanente Northwest and PacificSource. Practices must manage strict precertification portals, ambulatory surgical center carve-outs, and contracted fee schedule allowables.
Medicare Part A and Part B claims across Oregon are processed by Noridian Jurisdiction F. Noridian rigorously enforces Local Coverage Determinations (LCDs) on minor surgical interventions, physical therapy caps, diagnostic assays, and evaluation and management coding.
Under Oregon Revised Statutes § 743.911, insurers must pay clean electronic claims within 30 days. Claims unpaid within this statutory window accrue 9% annual interest payable to the healthcare provider. We track clearinghouse timestamps to enforce prompt claim adjudication.
Full-service billing and coding tuned specifically for Regence BlueCross BlueShield of Oregon / Moda Health contracts and Noridian (Jurisdiction F) Medicare coverage policies.
Learn MoreEnd-to-end RCM that tracks Oregon payer pre-authorization turnaround, secondary crossovers, and fee schedule compliance.
Learn MoreProvider enrollment and roster alignment across Oregon Medicaid programs, commercial networks, and hospital health systems.
Learn MoreTargeted historical audit analyzing 90 days of claims for Oregon underpayments, modifier misalignments, and prompt pay interest.
Learn MoreFront-desk patient intake, real-time insurance verification, and prior authorization handling without local staffing overhead.
Learn MoreReal-time performance analytics benchmarking your collection velocity against Oregon specialty peer averages.
Learn MoreHigh-intent patient acquisition for independent medical practices competing with consolidated hospital networks in Oregon.
Learn More| Oregon Payer Reality | The Generic Billing Trap | The MD Revenue Group Approach |
|---|---|---|
| 16 Regional CCOs | Submitting Medicaid claims to the wrong regional CCO, causing immediate batch rejection and cash flow delays. | We verify patient county residence and map claims directly to the contracted regional CCO clearinghouse. |
| HERC Prioritized List | Failing to pair diagnosis and procedure codes according to Oregon’s statutory Prioritized List coverage thresholds. | We pre-scrub claims against HERC line-item criteria to ensure medical necessity substantiation. |
| Noridian JF Medicare Governance | Submitting complex E/M visits or minor procedures without documenting medical decision-making complexity. | We audit clinical documentation against Noridian JF Local Coverage Determinations before claim generation. |
| ORS 743.911 Prompt Pay | Allowing commercial insurers to delay clean claim payments past 30 days without requesting the 9% annual interest penalty. | We log clearinghouse submission records and enforce statutory interest penalties on delayed claims. |
We analyze 90 days of recent claims data to uncover Regence contract shortfalls and Noridian modifier mismatches.
Targeted workflow fixes to address local prior authorization delays, Medicaid hurdles, and timely filing bottlenecks.
We establish seamless clearinghouse connections with Noridian, Medicaid, and commercial plans while your practice continues billing uninterrupted.
Transparent tracking toward 98%+ first-pass clean claim rate, under 32 average days in A/R, and maximized provider revenue.
Our Oregon team untangled Health Share CCO provider roster issues, resolved HERC diagnosis line-item rejections, and reduced average A/R to 28 days.
See What We Can Recover For YouOHA continues expanding health-related social needs (HRSN) benefits under its federal waiver, allowing CCOs to cover housing and nutrition supports.
Noridian is auditing claims billing joint injections, trigger point therapy, and minor skin excisions for medical necessity documentation compliance.
We audit specifically for Regence BlueCross BlueShield of Oregon / Moda Health fee shortfalls, Oregon Health Plan (16 Regional CCOs) credentialing holdbacks, and Noridian (Jurisdiction F) Local Coverage Determinations.
