Oregon Medicaid: DHS
Please follow the Enrollment Instructions below to become an electronic submitter for Oregon Medicaid.
Required Documents for those applying for new Submitter IDs
The following documents are required enrollment documents that must be completed, signed and returned to the DHS office prior to initiation of electronic claims submission or inquiry.
1. EDI Registration Form
2. Application for Authorization Form
3. Trading Partner Agreement
Required Documents for those with existing Submitter Ids but need to make changes to their account:
Use this form to change mailing address, email address, contact information, authorized users and EDI vendors.
1. Exhibit C to update your EDI registration
If the links above do not work properly, please download the forms directly from the website:
If you have any questions regarding any of the documents in this package, please phone the DHS EDI Technology Support Center at 1-800-527-5772.
We can now process 276/277 requests (claim status). If this is a transaction you would like to utilize please make sure to enroll with the payer.
Please select “A new registration”
Enter today’s date as the Effective Date
Enter your Business, Provider or Practice name
Enter your mailing address, phone number and fax number
Enter your Medicaid Provider number and your NPI
Enter your Taxonomy codes
NOTE: If you have more than one provider you must complete a separate Registration form for each.
Section 3, 4, 5 & 6
Complete these sections with the designated contact persons for these items in your office.
For Submitter Type: Choose “Billing provider” and “Self” if you are a provider using ClaimShuttle. (You are the EDI Submitter)
Note: If the provider is using a Billing Service fill in the Billing Service’s information in Section 5 & 6 and choose the “Billing Service” option for Submitter type. Section 7
Choose whether the transactions you will be billing are for FFS or Prepaid health plan
Choose either 837P or 837I
If you would like to receive your EOBs electronically, choose 835
Please sign and date this section
Application for Authorization
Please select “New Application”
Enter today’s date as the effective date
Enter your business name or provider name as the “trading partner”
Please select all the boxes
Complete the box at the bottom of Section A with your information (You are the trading partner)
Complete the box at the bottom of Section B with your information. (You are the EDI Submitter)
New applicants may leave the submitter number blank.
Note: If a provider is using a Billing Service that uses ClaimShuttle, the Billing Service’s information must be filled in here. The Billing Service’s submitter number must be provided in this section.
Complete section C with your information (You are the Trading Partner and the EDI Submitter)
New applicants may leave the submitter number blank.
Trading Partner Agreement
Please enter your Business, Practice, or Provider name
Complete the last section of this form.
Updating an Existing EDI Submitter ID
Those with existing Submitter IDs that need to make changes to their account should fill out the following forms.
Exhibit C to update your EDI registration
Use this form to change mailing address, email address, contact information, authorized users, the addition or deletion of authorized transactions or any other changes that may affect the accuracy of, or authority for, an EDI transaction. (Change forms must include the signature of your authorized primary or secondary signer.)
Please enter your trading partner information
Enter your Provider/Plan number
Enter your NPI and Taxonomy codes (A separate Exhibit C must be completed for each provider number.)
Please enter your Trading partner authorized signer information (cannot be a billing service or clearinghouse).
If the primary signer listed here is different from the one listed on your current TPA, you must complete a new TPA , Exhibit A and Exhibit B before we can update your EDI registration.
Please enter your Claims contact information (this should be someone from your office)
Please enter your information for the EDI submitter information
If this is different from what is on your current Exhibit A (DMAP 2081) and Exhibit B (DMAP 2082), you will also need to complete and submit a new Exhibit A and B. Note: If you are using a Billing Service, your Billing Service will be the EDI Submitter.
For Submitter Type, if you are using ClaimShuttle, choose “Self”. If you are using a Billing Service, choose “Billing Service”
If you are using ClaimShuttle, you are the EDI Submitter so please enter your information in this section.
If you are using a Billing Service then your Billing Service will be the EDI Submitter.
Select whether the claims you bill are FFS or PHP
Choose the transaction types that you want to either add or delete to your account.
Choose 837P or 837I
835 for Electronic EOBs
999 for Response reports
Please sign and date this section.
Submitting your Forms
It is recommended that you keep a copy of all the forms you will be submitting for your records. Mail the enrollment forms reflecting original signatures to:
Department of Human Services
Office of Medical Assistance Programs
Provider Enrollment Unit, E44
500 Summer St. NE Salem, OR 97301-1079
503-945-6898 (fax): 1-888-690-9888 (phone)
It is very important that you complete and return the entire enrollment packet as described above. Incomplete packets will not be processed and will be returned to the submitter.
Waiting for a Response
Once the complete provider enrollment packet has been received, the documents will be processed. Processing will take approximately two weeks from the date of receipt. (Remember that mailing time can take as much as five days.)
After processing, a confirmation will be faxed to you as notification to begin filing claims electronically. If neither confirmation nor a returned packet is received after two weeks, contact the DHS EDI Technology Support Center at 1-800-527-5772.
Once you have received your Submitter ID and password from DHS, please call the ClaimShuttle Support Team and set an appointment for a Mailbox setup and Test Transmission.
Please have 25 test claims ready for testing. Test files should consist of a variety of claims that represent the type of claims you will be submitting once production status is achieved. Test claims will not be processed for payment but will be validated against production files; therefore, they must contain valid patient procedure, diagnosis, and provider information.